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Anaesthesia 2013, 68, 846850

doi:10.1111/anae.12316

Original Article
Intra-operative correction of acidosis, coagulopathy and
hypothermia in combat casualties with severe haemorrhagic
shock
J. J. Morrison,1,2 J. D. Ross,3 H. Poon,1 M. J. Midwinter4 and J. O. Jansen5,6
1 Research Fellow and Specialty Registrar in General Surgery, 4 Defence Professor of Surgery, Academic Department of
Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK
2 Research Fellow and Specialty Registrar in General Surgery, US Army Institute of Surgical Research, Fort Sam
Houston, San Antonio, Texas, USA
3 Director, Trauma and Clinical Care Research, 59th Medical Wing, Science and Technology Ofce, Joint Base San
Antonio-Lackland, Texas, USA
5 Consultant in General Surgery and Intensive Care Medicine, 144 Parachute Medical Squadron, 16 (Air Assault)
Medical Regiment, Colchester, UK
6 Consultant, Departments of Surgery & Intensive Care Medicine, Aberdeen Royal Inrmary, Aberdeen, UK

Summary
We assessed acidosis, coagulopathy and hypothermia, before and after surgery in 51 combat troops operated on for
severe blast injury. Patients were transfused a median (IQR [range]) of 27 (1738 [584]) units of red cell concentrate, 27 (1638 [483]) units of plasma, 2.0 (0.53.5 [013.0]) units of cryoprecipitate and 4 (26 [017]) pools of
platelets. The pH, base excess, prothrombin time and temperature increased: from 7.19 (7.107.29 [6.507.49]) to
7.45 (7.407.51 [7.157.62]); from
9.0 ( 13.5 to
4.5 [ 28 to 2]) mmol.l 1 to 4.5 (1.08.0 [ 7 to
1
+11]) mmol.l ; from 18 (1521 [924]) s to 14 (1118 [921]) s; and from 36.1 (35.137.1 [33.038.1]) C to 37.4
(37.037.9 [36.038.0]) C, respectively. Contemporary intra-operative resuscitation strategies can normalise the
physiological derangements caused by haemorrhagic shock.
.................................................................................................................................................................

Correspondence to: J. O. Jansen


Email: jan.jansen@nhs.net
Accepted: 24 April 2013

The sequelae of haemorrhage the lethal triad of acidosis, coagulopathy and hypothermia are well recognised [13]. Damage control surgery an abbreviated
operation, secondary resuscitation in the intensive care
unit and subsequent denitive surgery has been associated with marked physiological derangement [4, 5].
Complications are common, including wound infection, abscesses, wound dehiscence, incisional herniation
and enterocutaneous stulation [3, 69]. The intraoperative correction of physiological and metabolic
846

disturbances would make primary surgery possible and


might reduce morbidity and mortality [5, 10].
Following the Vietnam War, patients in shock
received aggressive volume resuscitation with crystalloid
solutions [10]. A seminal review in 1997 stated crystalloid infusions of 812 l with 1822 units of packed
cells and 810 units of platelets are not unusual, and
that PT and PTT are most frequently elevated to 1.52
times control levels, and pH is on average 7.3 or lower
[2]. In contrast, contemporary resuscitation, developed

2013 Crown copyright. This article is published with the permission of the Controller of HMSO and the Queens Printer for Scotland.

Morrison et al. | Intra-operative correction of acidosis, coagulopathy and hypothermia

as a result of military experience in Iraq and Afghanistan, emphasises concurrent haemorrhage control and
resuscitation, minimisation of synthetic uid use and
proactive treatment of coagulopathy [5, 1115]. Several
recent studies have shown that this approach may be
associated with improved survival [1618], but there is
only limited evidence to demonstrate the effect on
patients physiological recovery.
The aim of this study was to determine whether
acidosis, coagulopathy and hypothermia can be
improved during surgery in combat casualties. The
predominant mechanism of wounding in Afghanistan
is blast injury, caused by improvised explosive devices,
and is characterised by traumatic leg amputation,
abdominopelvic injury and profound haemorrhagic
shock [5, 19]. High and bilateral leg amputations are
associated with increased mortality, partly due to the
difculties in controlling bleeding and the burden of
associated injuries [20]. Casualties therefore often
present with severe physiological and metabolic abnormalities.

Methods
This is a retrospective study of combat casualties treated between July 2008 and December 2010 at the medical treatment facility (Field Hospital) at Camp
Bastion, Helmand province, Afghanistan. The study
was approved by the Royal Centre for Defence Medicine (RCDM) Academic Unit. We used the UK Joint
Theatre Trauma Registry to identify consecutive casualties who had sustained at least one major (proximal
to ankle) leg amputation, and required laparotomy (for
abdominal injury or proximal control of torn leg
arteries).
Combat casualties in Helmand province were
evacuated by helicopter. Physicians or paramedics
attempted to control external haemorrhage with tourniquets and haemostatic dressings in-ight, and used
red cell concentrate and plasma to aid haemostasis.
The hospital was staffed by military emergency physicians, trauma surgeons, anaesthetists and intensivists
from the UK and the USA. Casualties identied as
being in extremis were immediately taken to the
operating theatre [5]. We followed a haemostatic resuscitation protocol. We transfused red cell concentrate
and plasma units in equal proportions, administered

Anaesthesia 2013, 68, 846850

pooled platelets after every ve units and cryoprecipitate after every ten units of red cell concentrate, as well
as tranexamic acid and calcium [5, 14, 2123]. In certain circumstances, we also used recombinant factor
VIIa or fresh whole blood. We used little in the way of
synthetic uids (such as starches), lactated Ringers
solution or 0.9% saline [21, 24]. All casualties had
venous blood sent for analysis as soon as vascular
access was established, usually within minutes of arrival
at the hospital. We sent further blood samples within
30 mins of arrival in the 12-bedded intensive care unit.
We extracted demographic and clinical details
from patients records. We reported the overall and
regional injury severities with the injury severity score
(ISS) and abbreviated injury scale (AIS), with a severe
injury dened as an AIS 3. We calculated the revised
trauma score (RTS) [25] from the admission respiratory rate, blood pressure and Glasgow coma scale,
which, when combined with the ISS, generated a
percentage predicted survival. An expected survivor
was dened as having a percentage predicted survival
greater than 50% [26].
The primary outcome was the normalisation of
acid/base status, coagulability and temperature. We
measured pH, base decit, prothrombin time and temperature on arrival to hospital and on admission to
the intensive care unit. Casualties who were taken to
the operating room, but died from lethal injury, were
not considered for further analysis.
We compared paired samples with Wilcoxon
matched-pairs signed-ranks tests. Statistical analyses were
conducted with Minitab (Minitab Inc, State College,
PA, USA), p < 0.05 indicating statistical signicance.

Results
We identied 67 consecutive casualties, but for administrative reasons, eight sets of records could not be
retrieved. The study cohort therefore consisted of 59
patients. Data were incomplete for three patients.
Table 1 lists patients characteristics: all 59 men
had lost legs (50/59 bilateral) from blast injuries
caused by improvised explosive devices. The severity
ISS and trauma scores RTS indicate severe injury and
physiological derangement.
The median (IQR [range]) time to hospital was
58 (3878 [42215]) min. A retrieval team led by

2013 Crown copyright. This article is published with the permission of the Controller of HMSO and the Queens Printer for Scotland.

847

Anaesthesia 2013, 68, 846850

Morrison et al. | Intra-operative correction of acidosis, coagulopathy and hypothermia

Table 1 Characteristics of 59 men with traumatic leg


amputation, requiring laparotomy, treated at Camp
Bastion between July 2008 and December 2010. Values
are median (IQR [range]) or number.

Age; years
Systolic blood pressure; mmHg
Glasgow coma score
Injury severity score
Revised trauma score
Predicted survival
Head AIS 3
Chest AIS 3
Abdominal AIS 3
Arm AIS 3
Leg AIS 3

25
90
3
30
4.1
26
4
9
15
15
59

(2129 [1845])
(72109 [0194])
(37 [315])
(2337 [1650])
(2.75.5 [0.67.5])

AIS, abbreviated injury scale.

physicians retrieved 51/59 patients; the remainder were


retrieved by paramedics. All patients had had tourniquets applied and 54/59 had topical haemostatic agents
applied to extremity bleeding. Circulatory access was
intra-osseous in 37 and intravenous in 28. Haemostatic
resuscitation was started before hospital arrival in 24
and anaesthesia was induced in 22 patients. Fifteen
patients needed thoracotomy.
Seventeen patients went directly to surgery on arrival and the rest spent 17 (925 [155]) pre-operative
minutes in the emergency department. All patients underTable 2 Operative management of casualties described
in Table 1. Values are numbers of patients (out of 59).

Resuscitative thoracotomy
External pelvic fixator
Abdominal surgery
Solid organ
Hollow organ
Vascular control
Non-therapeutic
Temporary closure

6
7
4
18
44
7
26

went laparotomy, either for suspected intra-abdominal


injuries or to obtain control of the iliac vasculature
(Table 2). Surgery lasted 3:20 (2:194:21 [0:349:00])
h:min. Nine patients suffered an intra-operative cardiac
arrest, from which ve were resuscitated with a sustained return of spontaneous circulation. Treatment
was limited to palliation in eight casualties who had suffered lethal injury, four of whom died in the operating
room and four shortly after admission to the intensive
care unit. Palliation was decided by consensus of at least
two experienced military consultant or attending surgeons, and the medical director.
The median (IQR [range]) transfusion requirements were: 27 (1738 [584]) units of red cell
concentrate; 27 (1638 [483]) units of plasma; 2.0
(0.53.5 [013.0]) units of cryoprecipitate; and 4 (26
[017]) pools of platelets (each containing 46 individual donor units). Thirty patients received a median of
2 (13 [18]) g tranexamic acid. Twenty-one patients
received recombinant factor VIIa.
The average pH, base decit, prothrombin time
and temperature of the 51 casualties treated with therapeutic intent improved intra-operatively (Table 3).
The predicted and observed survival rates were 26/51
and 46/51, respectively, p < 0.001. One patient died
shortly after admission to the intensive care unit: he
had had a cardiac arrest in the helicopter, from which
he was resuscitated, and subsequently underwent thoracotomy and laparotomy for haemorrhage control,
which was attained. However, he suffered a fatal cardiac arrest shortly after transfer to the intensive care
unit. The remaining four patients died of multiple
organ failure, in the intensive care unit, between 4 and
17 days after injury.

Discussion
We intentionally selected casualties with severe haemorrhage and profound shock. We demonstrated that they

Table 3 Comparison of physiological variables, before and after surgery, in 51 casualties treated with therapeutic
intent. Values are median (IQR [range]).
Before surgery
pH
Base excess; mmol.l 1
Prothrombin time; s
Core temperature; C

848

7.19
9.0
18
36.1

(7.107.29 [6.507.49])
( 13.5 to 4.5 [ 28 to
(1521 [924])
(35.137.1 [33.038.1])

After surgery
2])

7.45
4.5
14
37.4

(7.407.51 [7.157.62])
(1.08.0 [ 7 to +11])
(1118 [921])
(37.037.9 [36.038.0])

p value
<
<
<
<

0.001
0.001
0.001
0.001

2013 Crown copyright. This article is published with the permission of the Controller of HMSO and the Queens Printer for Scotland.

Morrison et al. | Intra-operative correction of acidosis, coagulopathy and hypothermia

can be resuscitated intra-operatively to physiological


normality. These ndings challenge the traditional
dogma that the lethal triad, once established, will
invariably be exacerbated by operative intervention.
Denitive treatment is possible during the rst
operation.
Our results corroborate those of two other recent
studies. Cotton et al. reported that fewer patients exhibited the lethal triad on admission to the intensive care
unit after changing practice to damage control resuscitation [16]. Higa et al. found that a more restrictive
approach to damage control surgery reduced complications, the number of re-operations and the length of
hospital stay, whilst increasing survival [9]. The authors
attributed their success to improved resuscitation, but
were unable to present physiological endpoints.
The contributions of the individual components of
modern combat casualty care treatment outside hospital, rapid haemorrhage control, coagulopathy limitation are difcult to determine. We agree with Cotton
et al. [16] and Higa et al. [9] that changes in transfusion strategies may be largely responsible for the
success of this approach. Our patients received virtually identical numbers of units of red cell concentrate
and plasma, which would have been unusual until a
few years ago. Nevertheless, we cannot demonstrate
causation as our study was uncontrolled. A comparison with historical controls would be confounded by
all the other changes in the care of combat casualties:
for instance, tranexamic acid is now used much more,
whilst recombinant factor VIIa is used less [5, 27, 28].
Although the mechanisms of injury are different
in civilian and military populations, the common pathophysiology of hypovolaemic shock makes the ndings
from this study generally relevant. Most civilian
patients are not as healthy as combatants, so the early
restoration of normal physiology may be even more
important, given their limited capacity to endure
derangement.
The intra-operative resuscitation of trauma
patients can normalise physiology, provided that
haemorrhage can be controlled.

Acknowledgements
We are grateful to the staff at the UK Joint Theatre
Trauma Registry, Royal Centre for Defence, Birmingham,

Anaesthesia 2013, 68, 846850

UK for assisting with the identication of patients. We


also thank Mr Paul Bontiff and his staff for assisting
with access to patient records at MoD Shoeburyness,
Essex, UK. We are also indebted to Dr C. William
Schwab MD (University of Pennsylvania) for his critical
appraisal of the study.

Competing interests
No external funding and no competing interests
declared.

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