The Trauma Triad of Death and Its Implications in EMS

Dispatched For a male patient shot in the leg. Upon arrival you find a 32 year old male patient sitting in his truck. was attempting to reholster his firearm while sitting in his truck when it accidentally discharged. The bullet penetrated his right thigh, causing immediate pain and profuse bleeding. During assessment the patient was found pale and diaphoretic with a rapidly expanding hematoma on his right thigh as well as a large exit wound actively bleeding. You apply a tourniquet to the patient’s leg and transfer him to the cot. Once on the cot you roll him to apply pressure dressings to the exit wound.

The patient is moved to the ambulance and start transport to the trauma center that is 25 minutes away. The patient complains of feeling lightheaded and was breathing rapidly. His initial blood pressure was 90/60 mmHg, heart rate was 110 bpm, and respiratory rate was 24 breaths per minute. Enroute you administer 1 gram of TXA per protocol and ensure the bleeding is controlled. Upon arrival at the hospital he receives blood products and surgery. Patient is released 4 days later for rehab.

Trauma remains a leading cause of mortality, especially among individuals under the age of 40¹. One of the critical challenges in managing trauma patients is the “Trauma Triad of Death,” which consists of hypothermia, coagulopathy, and acidosis². This triad is a lethal combination that can significantly impact the outcomes of trauma patients, especially when not addressed promptly and effectively.

Classifications of Hemorrhage and its Relation to the Trauma Triad of Death:

Hemorrhage in trauma patients is classified into four classes based on the estimated volume of blood loss and its physiological effects:

1. Class I Hemorrhage: Blood loss up to 15% of total volume. Typically, there’s little to no change in vital signs.
2. Class II Hemorrhage: Blood loss between 15-30% of total volume. Patients may present with tachycardia, a narrowed pulse pressure, and a slightly increased respiratory rate.
3. Class III Hemorrhage: Blood loss between 30-40% of total volume. There’s a marked decrease in blood pressure, increased heart rate, and a significant increase in respiratory rate. Mental status can be altered.
4. Class IV Hemorrhage: Blood loss greater than 40% of total volume. This is life-threatening and can lead to compensatory shock, profound hypotension, and altered mental status.

In the case above, his symptoms suggested he was approaching a Class III hemorrhage, which required immediate intervention.

The Trauma Triad of Death consists of:

1. Hypothermia: Drop in body temperature, which can impair blood clotting.
2. Coagulopathy: A disorder in which the blood’s ability to clot is impaired.
3. Acidosis: A condition in which body fluids contain too much acid, which can impair cellular functions.

In the context of hemorrhage:

• Significant blood loss can lead to hypothermia due to the loss of warm circulating blood and exposure to the environment.
• As the body loses blood, it can lead to coagulopathy due to the dilution of clotting factors, especially if large volumes of fluids or blood products are administered without appropriate ratios of clotting factors.
• Poor tissue perfusion due to hemorrhage can result in lactic acid buildup, leading to acidosis.

Together, these three factors can create a vicious cycle that exacerbates each other, leading to worsening outcomes in trauma patients. Immediate intervention to control bleeding, correct coagulopathy, and manage hypothermia and acidosis is crucial to break this cycle and improve patient outcomes.

Understanding the Trauma Triad of Death

1. Hypothermia: Hypothermia in trauma patients is a frequent occurrence, often exacerbated by traumatic hemorrhage leading to hypovolemic shock². This condition can further intensify due to environmental exposure at the scene of the accident, during transport, or even during medical procedures like infusions and airway management². Unintended hypothermia has been shown to worsen outcomes after major trauma¹.
2. Coagulopathy: Trauma-induced coagulopathy (TIC) describes abnormal coagulation processes resulting from trauma³. In the early stages, TIC presents as hypocoagulability, leading to bleeding. However, as it progresses, it can shift to a hypercoagulable state, increasing the risk of venous thromboembolism and multiple organ failure³.
3. Acidosis: Acidosis, often resulting from tissue injury and shock, can accentuate the effects of the trauma triad, further complicating the patient’s condition³.

The Importance of Managing Hypothermia in the Prehospital Setting

Early recognition and staging of hypothermia in the prehospital setting are crucial. It’s essential to start treatment at an early stage, especially focusing on preventing further cooling². Some studies have shown that certain hypothermia mitigation systems can be more effective in reducing heat loss and increasing patient comfort in the prehospital environment⁴. Moreover, these systems can facilitate clinical assessment, which is vital for determining the next steps in patient care⁴.

Just remember trauma naked can kill. It is vitally important that as you assess and inspect the patient for wounds we keep them covered.

Coagulopathy in EMS and the Role of Tranexamic Acid

Coagulopathy in the EMS setting, particularly following trauma, poses a significant challenge. Acute traumatic coagulopathy (ATC) can arise post-trauma, and if not addressed promptly, can lead to adverse outcomes¹. One of the promising interventions in this context is the administration of tranexamic acid (TXA). TXA is an antifibrinolytic agent that has garnered attention for its potential in preventing or managing ATC. A notable study, the PATCH-Trauma trial, investigated the administration of TXA in the prehospital setting for patients with severe trauma at risk of ATC². Another study highlighted the potential benefits of early TXA administration in trauma patients at risk of hemorrhage, emphasizing the importance of timely intervention⁴.

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References:

1. M. J. van Veelen, M. Brodmann Maeder. “Hypothermia in Trauma” ².
2. P. Caine, T. Zhelezniakova, M. Taylor, C. Smart, Simon Pennells, J. Hall. “Hypothermia Management, an Evaluation of a Novel Lightweight System” ⁴.
3. J. Shaw, B. Taylor, K. Thies. “Prehospital hypothermia is associated with increased mortality” ¹.
4. E. Moore, H. Moore, L. Kornblith, M. Neal, M. Hoffman, N. Mutch, H. Schöchl, B. Hunt, A. Sauaia. “Trauma-induced coagulopathy” ³.
5. B. Mitra et al. “Protocol for a multicentre prehospital randomised controlled trial investigating tranexamic acid in severe trauma: the PATCH-Trauma trial” ².
6. M. Bivens et al. “State-by-state estimates of avoidable trauma mortality with early and liberal versus delayed or restricted administration of tranexamic acid” ⁴.