Hemorrhage is the most common cause of traumatic hypotension and shock and is, after head injury, the second most common cause of death after trauma (Table 52-1: Guidelines for Management of Traumatic Shock).

1. Patients with significant intra-abdominal fluid recognized with these tests and hemodynamic instability require immediate surgical intervention.
2. Those who are suspected to have occult abdominal bleeding based on a high-risk mechanism of injury but who are hemodynamically stable must undergo further evaluation with CT.
3. Clinical assessment using hemodynamic data is based on a few relatively insensitive and nonspecific clinical signs. (Tachycardia as an index of hypovolemia may be absent in up to 30% of hypotensive trauma patients because of increased vagal tone.)
   1. Although traditional vital signs are relatively unreliable for recognizing life-threatening shock, heart rate, systemic blood pressure, pulse pressure, respiratory rate, urine output, and mental status are still used as early clinical indicators of the severity of hemorrhagic shock (Table 52-2: Advanced Trauma Life Support Classification of Hemorrhagic Shock).
   2. The response to initial fluid resuscitation in the form of lactated Ringer's solution (LRS) or normal saline solution of about 2 L or 20 mL/kg in children over a period of 15 to 30 minutes may permit estimation of the severity of hemorrhage (Table 52-3: Response to Initial Fluid Administration).
4. Crystalloids are used in the vast majority of trauma centers for initial resuscitation. (There is no difference in the mortality rate between patients receiving crystalloids and those receiving colloids.) Hydroxyethyl starch solutions (maximum, 20 mL/kg) should probably be given priority over albumin solutions. (Possible deleterious effects of colloids have mostly been associated with albumin.)
5. Some of the proven markers of organ perfusion can be used during early management to set the goals of resuscitation. Of these, the base deficit and blood lactate level are the most useful and practical tools during all phases of shock, including the earliest.
   1. Base deficit is considered a better prognostic marker than the arterial pH. (Normalization of the base deficit is one of the end points of resuscitation.)
   2. Elevation of the blood lactate level is less specific than base deficit as a marker of tissue hypoxia. Nevertheless, in most trauma victims, an elevated lactate level correlates with other signs of hypoperfusion, rendering it an important marker of dysoxia and an end point of resuscitation.
6. Measurement of hemoglobin (Hgb) or hematocrit (Hct) helps in managing bleeding trauma patients. However, decision making based on a single Hct value may lead to erroneous management decisions. (Trauma patients, if not treated with adequate crystalloids or colloids, or those receiving packed red blood cell [PRBC] transfusion, can maintain a normal Hct despite ongoing bleeding.)
   1. Serial Hct measurements and consideration of the type and amount of fluid received may be useful in deciding the timing and amount of transfusion.
   2. The recommended target Hgb concentration in all phases of management is 7 to 9 g/dL, including brain-injured patients in whom tissue oxygenation is most relevant. This concern should not preclude timely and adequate administration of blood products.
7. One of the principal goals during early management of a hemorrhaging trauma victim is to avoid the development of the so called “vicious cycle” or “lethal triad” consisting of acidosis, hypothermia, and coagulopathy (Fig. 52-3: Schematic representation of the “bloody vicious cycle” or “lethal triad.”).
   1. Both acidosis and hypothermia are major factors in the induction of coagulopathy.
   2. Bleeding and intravascular coagulation further augment coagulopathy via loss or consumption of damaged or depleted platelets and coagulation factors.
   3. The practice of administering large volumes of crystalloids, colloids, and PRBCs with no hemostatic components for initial resuscitation is considered to be the major factor in the development of often lethal coagulopathy.
   4. Rapid establishment of venous access with large-bore cannulae placed in peripheral veins that drain both above and below the diaphragm is essential for adequate fluid resuscitation in a patient who is severely injured. (Ultrasound guidance may facilitate cannulation of the internal jugular vein.)

Trauma and Burns

1. Initial Evaluation and Resuscitation
2. Cervical Spine Injury
3. Direct Airway Injuries
4. Management of Breathing Abnormalities
5. Management of Shock
6. Early Management of Specific Injuries
7. Burns
8. Operative Management
9. Management of Intraoperative Complications
10. Electrolyte and Acid–Base Disturbances
11. Early Postoperative Considerations