Page 64 - JSOM Winter 2019

Getting “SMART” on Shock Treatment

An Evidence-Based Mnemonic Acronym
for the Initial Management of Hemorrhage in Trauma

Patrick Thompson ; Anthony J. Hudson, FRCPEd, FRCEM 2
1

ABSTRACT
Treating hemorrhagic shock is challenging, the pathology is introduction of training programs to address the challenges of
complex, and time is critical. Treatment requires resources in reducing preventable death due to traumatic injuries is highly
mental bandwidth (i.e., focused attention), drugs and blood effective if the appropriate training, resources, and commit-
products, equipment, and personnel. Providers must focus on ment from the command hierarchy are implemented. 4
treatment options in order of priority while also maintaining a
dynamic assessment of the patient’s response to treatment and Cognitive Strategies to Optimize Decision-Making in
considering potential differential diagnoses. In this process, High-Stress Environments
the cognitive load is substantial. To avoid errors of clinical
reasoning and practical errors of commission, omission, or be- Care of patients with severe traumatic injuries, particularly
coming fixated, it is necessary to use evidence-based treatment the initiation of remote damage control resuscitation in hostile
recommendations that are concise, in priority order, and easily or austere environments, represents one of the most stressful
recalled. This is particularly the case in the austere, remote, or challenges in clinical medicine. Responsibility for the initial
5
tactical environment. A simple mnemonic acronym, SMART, resuscitation of critically injured patients often falls to their
is presented in this article. It is a clinical heuristic that can be medically trained comrades or relatively inexperienced front-
used as an aide-mémoire during the initial phases of resuscita- line medical personnel. The risk of cognitive error is increased
tion of the trauma patient with hemorrhagic shock: Start the in such settings and so an understanding of why mistakes oc-
clock and Stop the bleeding; Maintain perfusion; Administer cur and how to avoid them is important in structuring training
antifibrinolytics; Retain heat; Titrate blood products and cal- of personnel and the provision of appropriate decision-sup-
cium; Think of alternative causes of shock. port tools. Similarly, providers must be aware of the risks
6,7
of cognitive bias and strategies to minimize the risk of this oc-
8,9
Keywords: hemorrhage; shock; treatment; mnemonic; acro- curring. In such high-stress, time-critical environments, the
nym; heuristic use of checklists is recommended and widely acknowledged to
reduce stress and improve performance. 10
Although the use of written checklists may be impractical in
Introduction
such uncompromising environments, there is evidence that
Trauma remains a significant cause of death worldwide in other cognitive aids, including mnemonics, can improve the
all societies. Injury to the central nervous system (including retention and recall of key information in medical settings. 11–13
1
traumatic brain injury) is the overall leading cause of death Heuristic decision-making with the aid of simple mnemon-
from trauma, but hemorrhage is estimated to be responsible ics has the potential to improve accuracy and speed of de-
for 40% to 50% of deaths resulting from traumatic injury. cision-making in complex, high-stress settings. Although
2
14
One comprehensive review of military battlefield deaths found mnemonic acronyms such as C-ABCDE (catastrophic hemor-
that hemorrhage is the leading cause of death for patients rhage, airway with spinal protection, breathing, circulation,
deemed to have succumbed to potentially survivable injuries, disability [neurological] and exposure and environment) or
3
with most of these occurring in the prehospital environment. MARCH (massive bleeding, airway, respiration, circulation,
Eastridge et al. concluded that 24.3% of the deaths occurring head and hypothermia) are already widely used to guide the
3
before patients reach a medical treatment facility were poten- overall order of resuscitation priorities for trauma patients,
tially survivable, but the researchers highlighted that 90.9% of these mnemonics give no triggers to recall the detail of what
these were due to hemorrhage. Furthermore, 67.3% of these treatments are required to manage life-threatening hemor-
deaths due to hemorrhage were attributed to truncal hemor- rhage—the commonest cause of potentially preventable death
rhage. Hence, in remote settings, when surgical management due to trauma. There is a risk that medical providers in highly
of truncal hemorrhage is rarely available, it is vital that prehos- stressed environments may be unable to recall which time-crit-
pital care providers are trained and equipped to manage cata- ical interventions need to be delivered to remedy “circulation”
strophic hemorrhage and, when necessary, to maintain critical problems as they are identified in the initial assessment and
perfusion with appropriate resuscitation fluids. The systematic treatment of the shocked trauma patient.
*Correspondence to Dr Tony Hudson, Emergency Department, Royal Devon & Exeter NHS Foundation Trust, Barrack Road, Exeter EX2 5DW,
Devon, UK or anthony.hudson1@nhs.net
1 Mr Thompson is a UK paramedic. Dr Hudson is affiliated with the Department of Emergency Medicine, Royal Devon & Exeter NHS Foun-
2
dation Trust, Exeter, Devon, UK.
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