Computerized clinical decision support for traumatic shock resuscitation

Abstract

To review what we learned through implementation of computerized decision support for ICU resuscitation of major torso trauma patients who arrive in shock. Overall, these patients respond well to preload-directed goal-orientated ICU resuscitation; however, the subset of patients destined to develop abdominal compartment syndrome do not respond well. In fact, this strategy precipitates the full-blown syndrome that is a new iatrogenic variant of multiple organ failure. The clinical trajectory of abdominal compartment syndrome starts early after emergency department admission and its course is fairly well defined by the time patients reach the ICU. It occurs in patients who arrive with severe bleeding that is not readily controlled. These patients require a very different emergency department management strategy. Hemorrhage control is paramount. Alternative massive transfusion protocols should be used with an emphasis on hemostasis and avoidance of excessive isotonic crystalloids. Finally, near-infrared spectroscopy that measures tissue hemoglobin saturation in skeletal muscle (StO2) is good at identifying high-risk patients. A falling StO2 in the setting of ongoing resuscitation is a harbinger of death from early exsanguination and multiple organ failure. Fundamental changes are needed in the care of trauma patients who arrive in shock and require a massive transfusion.