HYPOTHERMIA, COAGULOPATHY, AND ACIDOSIS

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The damage control approach to severely injured patients is not a new concept, having been used at least as early as World War II in the management of severe liver trauma. Easier availability of high-powered firearms20 and liberalization of speed limits8 have increased the overall severity and number of injuries sustained in the civilian population. Improvements in operative techniques and resuscitation strategies now allow these severely and multiply injured patients to survive long enough to exhibit extreme derangements in physiology that would have been considered unusual and fatal in the past. Specifically, the triad of hypothermia, acidosis, and coagulopathy now commonly is encountered by trauma surgeons. This triad is recognized easily, becomes apparent early in the patient's course, and is the trigger for adopting a damage control strategy. No longer is the abbreviated celiotomy with staged definitive reconstruction seen as a sign of surgical insufficiency; rather, it is the sign of a surgeon who puts the well-being of the patient above the axiom to repair all injuries definitively although the patient is at the limits of physiologic exhaustion. If these patients are to survive to the reconstruction phase, the early signs of developing physiologic exhaustion must be recognized, and aggressive and meticulous resuscitative efforts must occur. These efforts involve all organ systems, and, when successful, produce measurable resolution of hypothermia, acidosis, and coagulopathy. This article describes the evaluation and management options currently employed in patients with this deadly triad.

Section snippets

Monitoring

In humans, hypothermia is defined as a core body temperature below 35°C. A decreasing core temperature leads to physiologic abnormalities (Table 1). The ideal way to measure temperature would be continuous, accurate, minimally invasive, easy to use, and inexpensive. No existing monitoring system fulfills all these criteria. Methods that have been used include measurement of the temperature of the skin, oro- or nasopharynx, esophagus, tympanic membrane, bladder, rectum, and pulmonary arterial

Diagnostic Methods

Coagulopathy—as part of the deadly triad of hypothermia, coagulopathy, and metabolic acidosis—is common. Its presence is first suggested to the surgeon by diffuse oozing of all cut surfaces. Four events contribute to post-traumatic coagulopathy: hemodilution, consumption of clotting factors, hypothermia, and metabolic derangements (e.g., acidosis). Dilutional thrombocytopenia is the most common coagulation abnormality in trauma patients, and is particularly common in patients receiving more

Monitoring

Acidosis is defined as an arterial pH less than 7.36. Although respiratory acidosis is not uncommon in the critically ill trauma patient, the acidosis of most interest in this situation is the lactic type of metabolic acidosis. In addition to pH, other indicators also can suggest that a state of oxygen debt exists: base deficit and serum lactic acid levels.

Arterial pH must be interpreted in the context of arterial carbon dioxide tension. Analysis of the arterial P co2 helps to differentiate a

SUMMARY

The management of patients requiring a damage control approach taxes the abilities of the best equipped trauma center. These patients present with severe metabolic abnormalities, most notably characterized by a deadly triad of hypothermia, coagulopathy, and acidosis. Using volumetric, oximetric pulmonary artery catheters, hypothermia and any ongoing cardiovascular abnormalities can be identified quickly and treatment can be monitored. External, forced air rewarming is a valuable technique in

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    Address reprint requests to Virginia A. Eddy, MD, Division of Trauma, Section of Surgical Sciences, Department of Surgery, Vanderbilt University Medical Center, 243 Medical Center South, Nashville, TN 37212

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    Division of Trauma, Section of Surgical Sciences, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee

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