Page 66 - JSOM Winter 2019

of injury. Therefore, tranexamic acid should be given as soon providers must consider pausing at the end of the initial inter-
as possible. This effect was also demonstrated in a military ventions to manage hemorrhagic shock to consider whether
25
setting in the Military Application of Tranexamic Acid in there may be other causes for the shock state, particularly if
Trauma Emergency Resuscitation study. 26 the patient has failed to respond to any of the aforementioned
R – Retain heat interventions. Cognitive psychology suggests that such use of
• Achieve and maintain normothermia. slower, System 2 thinking further reduces the risk of error in
The detrimental effects of hypothermia and hyperthermia on such settings. 32
coagulation and, hence, death have been clearly demonstrated
and so providers must take measures to retain heat and main- FIGURE 1 Key actions indicated by the SMART mnemonic for
tain normothermia. 27 treatment of hemorrhagic shock.
T – Titrate blood products and calcium
• Fresh whole blood (FWB) improves survival compared
with administration of 1:1 plasma and red blood cells
(RBCs)
• If FWB not available, then plasma, RBCs, and platelets
should be administered in a 1:1:1 ratio.
• If platelets not available, then plasma and RBCs should
be administered in a 1:1 ratio.
• If not available, then use reconstituted dried plasma,
liquid plasma, or thawed plasma alone or RBCs alone. Conclusion
• Give calcium, especially when giving citrated blood
products. In this article, an evidence-based mnemonic acronym has been
• Administer fibrinogen if there is functional deficit or presented that is designed to aid retention and recall of the
plasma fibrinogen level is below 1.5–2.0g/L. 21 key treatment strategies in the initial resuscitation of patients
Appropriate blood products should be administered as early as with hemorrhage in trauma. Evidence suggests the implemen-
possible for patients with traumatic injuries who have evidence tation of such cognitive aids may enhance recall of key in-
of organ hypoperfusion. In resource-poor settings, this may be formation and reduce stress when medically trained personnel
based purely on loss of radial pulse, but when blood pressure are required to treat time-critical injuries in hostile or austere
monitoring is available, then a shock index (heart rate/systolic environments.
blood pressure) greater than 1 predicts the need for massive
transfusion. Schreiber et al. identified variables for patients Author Contributions
29
28
arriving at combat support hospitals in Iraq that predicted the PT conceived the mnemonic. AH made critical suggestions and
need for massive transfusion, but these investigations are rarely wrote the first draft of the manuscript. PT and AH reviewed
available in the prehospital environment. Another assessment the relevant literature and read, revised, and approved the fi-
tool that predicts the need for massive transfusion has been nal manuscript.
adopted by the US Army 75th Ranger Regiment for the pre-
hospital administration of whole blood. This suggests that Disclosures
30
the critical values for initiating transfusion are a systolic blood The authors have indicated that they have no financial rela-
pressure between 80 and 100mmHg or lower, lactate level of tionships relevant to this article to disclose.
5mmol/L or higher, heart rate greater than 100 bpm, and tis-
sue oxygen saturation not more than 70%. The Norwegian References
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31

alty Care has published an evidence-based recommendation of preventable death on the battlefield. Arch Surg. 2011;146(12):
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64 | JSOM Volume 19, Edition 4 / Winter 2019