TRAUMA TRIAD OF DEATH SERIES

The patient is then rapidly transported to the intensive care unit for resuscitation in order to restore sufficient physiologic reserve to allow return to the operating room for definitive repair and reconstruction ( 1-3).Īlthough retrospective in nature, studies have documented a nearly 50% decrease in operative times for the most severely injured patients treated by this approach, and salvage rates of 20–60% in patients who formerly died in the operating room ( 2, 4). Techniques for abbreviating operations include ligation of intestinal injuries without anastomoses, leaving retained clamps on injured vascular structures or placement of temporary intralumenal shunts, packing diffusely bleeding surfaces with multiple laparotomy pads, and using towel clips to quickly close the skin, leaving the underlying fascia open. A minimal operation is initially performed solely to reduce or control surgical bleeding and enteric spillage.

TRAUMA TRIAD OF DEATH SERIES

It can be defined as a series of operations performed during several trips to the operating room at intervals of several hours to days, in order to accomplish definitive repair in a staged manner in accordance with the patient's physiologic tolerance. Staged laparotomy, also known as abbreviated laparotomy, or “damage control,” is a new, important, rapidly expanding surgical approach to treating unstable patients. This triad presented as a vicious cycle that often could not be interrupted, and patients frequently died in the operating room due to “irreparable injuries.” In many of these patients progressive intraoperative deterioration in physiology occurred, typically manifested as hypothermia, coagulopathy, and acidosis. The burden was on the anesthesiologist to provide sufficient intraoperative critical care so that the surgeon had sufficient time to definitively repair all injuries. If the patient returned to the operating room for postoperative bleeding the surgeon was considered to have performed an inadequate operation. Prolonged operative times were common in patients with multiple injuries such as massive liver trauma, abdominal vascular trauma, retroperitoneal injuries, multiple intestinal disruptions, chest trauma, and open fractures. The historical objective of laparotomy was to provide definitive hemostasis, repair of all injuries, and control of enteric contamination by resection of bowel injuries, followed by anastomosomes or ostomy formation. This has presented a new challenge for critical care physicians, who must now address problems that previously burdened anesthesiologists during lengthy operations on unstable patients. This article explores the pathogenesis and treatment of acidosis, hypothermia, and coagulopathy as it applies to the exsanguinating trauma patient.Operative goals for trauma patients with severe multisystem injuries have changed in recent years. Critical care nurses must underetand this triad, because it forms the basis and underlying logic on which the damage control philosophy has been built. The “new” golden hour may well be the time in the operating room before the patient reaches the physiologic limit, defined as the onset of the triad: hypothermia, acidosis and coagulopathy. As the shift in care of patients in extremis has continued to move from the street to the emergency department and beyond, the focus of trauma resuscitation has shifted to the operating room and ultlmately to the intensive care unit. The concept of the “golden hour” has translated into unprecedented speed and efficiency of trauma resuscitation with the ultimate goal of short injury-to-incision times. With the organization of trauma systems, the development of trauma centers, the application of standardized methods of resuscitation, and improvements in modern blood banking techniques, the ability to aggressively resuscitate patients in extremis has evolved.

Trauma triad of death