SUPPLEMENT ARTICLE
Resuscitation and Treatment of Shock
Michael J. Beltran, MD,* Tyson E. Becker, MD,† Richard K. Hurley, MD,*
Jennifer M. Gurney, MD, FACS,‡ and Roman A. Hayda, MD§
Summary: Hemorrhage continues to be the most common cause of
Downloaded from https://journals.lww.com/jorthotrauma by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3c9CHBlrWfCoRwpdiHT4x479s3qzjDcJUeDg9FpuoCVpi0gt7Wz035A== on 08/20/2019
death among service members wounded in combat. Injuries that were
previously nonsurvivable in previous wars are now routinely seen by
combat surgeons in forward surgical units, the result of improvements in
body armor, the universal use of field tourniquets to control extremity
hemorrhage at the point of injury, and rapid air evacuation strategies.
Combat orthopaedic surgeons remain a vital aspect of the forward
surgical unit, tasked with assisting general surgical colleagues in the
resuscitation of patients in hemorrhagic shock while also addressing
traumatic amputations, open and closed long bone fractures, and
mechanically unstable pelvic trauma. Future military and civilian trauma
research endeavors will seek to identify how the advances made in the
past 15 years will translate toward the emerging battlefield of the future,
one where forward surgical units must be lighter, smaller, and more
mobile to address the changing scope of military combat operations.
Key Words: shock, hemorrhage, damage control, resuscitation
(J Orthop Trauma 2016;30:S2–S6)
INTRODUCTION
The war on terrorism has been marked by continuous
conflicts in Iraq, Afghanistan, and other theaters for the past
15 years. Distinct from previous conflicts, recent wars have
seen a far greater percentage of injuries occur as a result of
blast mechanisms; these injuries lead to the greatest utilization
of resources and long-term patient disability.1,2 One hallmark
injury of these conflicts has been devastating but survivable
extremity trauma. Patients with severe, previously fatal
extremity injuries are now surviving as a result of advances
made on the modern battlefield, including the use of field
tourniquets, rapid air evacuation to forward surgical units,
and early and aggressive resuscitation strategies, all of which
occur in far forward austere facilities. These military advances
have been extrapolated to mass casualty and other disaster
management scenarios outside of combat theaters of opera-
tion, with no area more pronounced in its effect on survival
Accepted for publication July 19, 2016.
From the *Department of Orthopaedic Surgery, San Antonio Military Medical
Center, San Antonio, TX; †Department of Surgery, Trauma and Critical
Care, San Antonio Military Medical Center, San Antonio, TX; ‡United
States Army Institute of Surgical Research; and §Department of Orthopae-
dic Surgery, Brown University, Providence, RI.
R. A. Hayda is on executive board for METRC (research consortium). The
remaining authors report no conflict of interest.
Reprints: Michael J. Beltran, MD, Department of Orthopaedic Surgery, San
Antonio Military Medical Center, 3551 Roger Brooke Drive, San Antonio,
TX 78234 (e-mail: mbeltran0514@gmail.com).
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
DOI: 10.1097/BOT.0000000000000670
S2 | www.jorthotrauma.com J Orthop Trauma  Volume 30, Number 10 Supplement, October 2016
Copyright Ó 2016 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
than that of patient resuscitation and the treatment of hemor-
rhagic shock.3–6
Patients with orthopaedic trauma sustained in combat
frequently present in hemorrhagic shock as a result of traumatic
amputations, open long bone fractures with massive soft tissue
injuries, and pelvic ring disruptions. As part of forward surgical
units, military orthopaedic surgeons are engaged not just in the
management of orthopaedic injuries but rather in the total care
of the traumatized patient. Combat orthopaedic surgeons must
therefore be comfortable with patient resuscitation strategies,
close coordination with general surgeons, and the temporizing
measures necessary to manage extremity and pelvic trauma
before evacuation, directly contributing to survival and long-
term functional outcomes.
DEFINITION OF SHOCK AND PRINCIPLES
OF RESUSCITATION
Definition of Shock
Shock is defined as failure of the cardiovascular system
to provide adequate perfusion and oxygenation to organs and
tissue.7 These effects, while initially reversible, rapidly become
irreversible and often fatal if the underlying etiology is not
treated promptly. Although hemorrhage is by far the most
common etiology managed in combat, other forms of shock
can occur to include obstructive shock due to tension pneumo-
thorax or cardiac tamponade or neurogenic shock, which must
be ruled out during the primary survey.8–10
Principles of Resuscitation
The widespread use of body armor in combat has left
penetrating extremity trauma as the most common source of
bleeding in the patient presenting with shock. Identifying and
stopping sources of continued bleeding is the first and most
important step in the primary survey, occurring before both
airway and breathing assessment.11,12 This hypervigilance to
seek and immediately stop ongoing blood loss stems from
historical war data demonstrating that 50% of combat deaths
are from hemorrhage and from more recent data demonstrating
that 91% of potentially survivable prehospital deaths in Iraq and
Afghanistan over a 10-year period were due to hemorrhage.10,11
During the primary survey, if a source of significant
hemorrhage is identified, it is immediately addressed while
continuing the patient assessment. The Tactical Combat Casu-
alty Care (TCCC) guidelines recommend the use of extremity
tourniquets early in the prehospital environment for bleeding
wounds not controlled by pressure dressings.13–15 This has led to
a significant reduction in combat deaths related to exsanguina-
tion from extremity wounds and has resulted in presentation of
J Orthop Trauma  Volume 30, Number 10 Supplement, October 2016
more casualties to surgical facilities with tourniquets placed
immediately at the time of injury by combat medics, battle
buddies, and other soldiers. Tourniquets should remain in place,
especially while still in shock, until the extremity can be as-
sessed in the operating room and surgical control obtained.
Bleeding not controlled with a tourniquet should be assessed
for effectiveness because tourniquet “tightness” must increase if
thigh or arm swelling occurs.16
The use of field tourniquets is simple but requires
a working knowledge of how they function to avoid common
pitfalls during application. When not adequately tightened,
a paradoxical increase in bleeding will occur because arterial
inflow is not fully occluded but venous outflow is blocked.17
If one field tourniquet is not effective, placement of a second
immediately proximal may be necessary for hemorrhage con-
trol. Pneumatic tourniquets should be applied as secondary
tourniquets when available.18
Bleeding wounds of the trunk, axilla, and groin pose
a significant challenge, especially in the prehospital setting
because these areas are not amenable to control using
tourniquets. TCCC guidelines recommend treatment for these
areas with topical hemostatic dressings and direct pressure;
Combat Gauze is the first line choice.19 Junctional tourniquets
such as the Combat Ready Clamp have been shown to be
effective in case series and studies in healthy volunteers and
are currently approved by Food and Drug Administration. They
are recommended by the TCCC for use in the prehospital
environment when available because direct pressure during
patient movement on the battlefield is difficult.20,21 At a surgical
facility, these wounds should be controlled with direct pressure
or balloon tamponade. Foley catheters are universally available,
easy to use, and effective as balloon tamponade devices until
the patient can be rapidly transported to the operating room to
obtain surgical control. They can be used for small bleeding
wounds of the axilla, torso, and groin that are difficult to con-
trol; the balloon (ideally 30 cm3) is inflated and secured at skin
level. In mass casualty scenarios, patients with effective limb
tourniquets in place may be triaged to follow patients with
uncontrolled hemorrhage to the operating room but should be
prioritized accordingly because the risk of progressive and per-
manent neuromuscular injury increases with ischemia time and
becomes significant and potentially irreversible at 4+ hours.16
Although extremity and truncal open wounds are
obvious as sources of bleeding, adjuncts are often necessary
in the forward environment to diagnose more occult sources of
bleeding from the chest and abdomen. Forward surgical units
now have routine access to plain radiography and/or ultra-
sound, allowing for focused assessment with sonography in
trauma (FAST) examination and a chest x-ray during the
secondary survey. FAST is effective at diagnosing both
abdominal hemorrhage and pericardial tamponade, but has its
limitations, particularly assessment of the retroperitoneal space.
Despite early enthusiasm for FAST, recent studies have
demonstrated sensitivities as low as 22% in hemodynamically
stable and 28% in hemodynamically unstable patients.22 Diag-
nostic peritoneal aspiration remains an effective tool to assess
for intraabdominal hemorrhage when suspicion is high and the
FAST examination is negative because computed tomography
is unavailable in forward surgical units. Aspiration of any
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Copyright Ó 2016 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Resuscitation and Treatment of Shock
amount of blood is considered a positive test; therefore, diag-
nostic peritoneal aspiration is simpler than lavage, with a sensi-
tivity of 89% and specificity of 100% in detecting hemorrhage
significant enough to cause hypotension.23,24
Early recognition of shock should be quickly followed by
aggressive use of fluids, blood products, and thrombostatic
medications for resuscitation, particularly in those meeting
criteria for massive transfusion (MT). Current recommenda-
tions, based on military studies from the past 15 years and
confirmed in the civilian trauma literature, call for an effective
transfusion ratio of packed red blood cells, fresh frozen plasma
(FFP), and platelets of as close to 1:1:1 as possible. Surgeons
should administer blood products as soon as possible; crystal-
loids need not be given first and have been associated with
increased rates of Acute Respiratory Distress Syndrome,
abdominal compartment syndrome, multisystem organ failure,
and death. Tranexamic acid is also effective as a first-line agent
for control of hemorrhage and should be given as soon as shock
is diagnosed because its benefit is most pronounced when given
within 1 hour of injury and is most effective in those requiring
MT (.10 units of blood products in 24-hour period).25,26 Tra-
nexamic acid should be dosed at 1000 mg over 10 minutes
initially, with a repeat dose of 1000 mg over 8 hours.
Massive Transfusion
MT scenarios can quickly exhaust a forward unit’s entire
supply of blood products, and in these situations, MT protocols
should be initiated, which may include whole blood transfusion
as part of a unit-based blood drive. Fresh whole blood is warm,
provides a higher hematocrit, platelet count, coagulation factor
activity, and fibrinogen than 1:1:1 component therapy—with
10 U of cryoprecipitate.27 The main risk of whole blood use is
a fatal acute hemolytic reaction; recommendations for whole
blood use in the deployed environment include type-specific
blood.28 Finally, recombinant activated factor VII (factor VIIa),
whose use was popular early in the conflicts, is currently not
a part of any military protocols or algorithms for dealing with
MT scenarios or ongoing hemorrhage due to studies being
mixed with regard to survival benefit and risk of thrombotic
events.29,30
Two recent emerging adjuncts to control massive hemor-
rhage in the combat environment are the administration of
freeze-dried plasma (FDP) and the technique of retrograde
endovascular balloon occlusion of the aorta.31–35 Retrograde en-
dovascular balloon occlusion of the aorta is an emerging tech-
nology to provide intraluminal aortic control of noncompressible
truncal hemorrhage. Although first described in the Korean War,
renewed interest has emerged in complex war trauma. The tech-
nique involves placing an endovascular balloon from the com-
mon femoral artery to the level of the descending aorta,
occluding distal flow. It is considered for use as an alternative
to resuscitative thoracotomy and external occlusion of the aorta
in cases of traumatic arrest or profound shock with systolic
blood pressure ,90 mm Hg. It may have the most mortality
benefit when used early in patients at significant risk of profound
hemorrhagic shock who have not yet arrested, increasing sys-
tolic blood pressure by a mean of 53 mm Hg and maintaining
perfusion to the heart and central nervous system during resus-
citation before formal surgery to address the bleeding etiology.33
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Beltran et al J Orthop Trauma  Volume 30, Number 10 Supplement, October 2016
FDP represents a life-saving product being used on the
battlefield and in select civilian trauma centers. FDP has
similar efficacy to FFP in treating coagulopathy but has an
extended 2 years shelf life, can be stored at room temperature,
can be made ABO-universal, and reconstitutes with ease.32,33
Despite concerns regarding disease transmission due to blood
pooling, a recent study using FDP at a deployed French field
hospital showed similar efficacy to standard FFP with no
adverse events.36
DAMAGE CONTROL ORTHOPAEDICS
Combat-injured patients with extremity fractures, trau-
matic amputations, and/or pelvic ring injuries benefit from
temporizing treatment approaches downrange. Timing of
early antibiotic coverage and surgical control of extremity
hemorrhage take precedence over prompt debridement and
spanning external fixation, which can be performed if time
and patient status allow but which should never delay
evacuation to a higher level of care for life-threatening chest,
abdominal, or head injuries. Current recommendations for
combat-related open fractures include gram-positive coverage
with a cephalosporin and recommend against use of amino-
glycosides for gram-negative coverage.37 Although numerous
indices (lactate, base deficit, IL-6) are available to guide deci-
sion making and categorize patients regarding early total care
versus damage control surgery in a civilian setting, they are of
limited value in an austere theater of operations; definitive
surgery is best performed after evacuation out of theater to
a fixed military hospital. External fixators are effectively
applied to manage open and closed lower extremity long bone
fractures; they can be applied quickly and safely, without the
use of fluoroscopy, and are readily available in both mobile
and fixed forward surgical units.38 Traumatic amputations,
although benefiting from early debridement and hemorrhage
control, should never be shortened downrange but maintained
at maximal length that bone and soft tissues allow. Even if an
adjacent proximal fracture is present, only devitalized and
highly contaminated tissue is excised to allow for length
preservation with proven methods to stabilize fractures in
the residual limb once evacuated.39
Addressing Vascular Injuries
Penetrating extremity trauma frequently is associated
with vascular injury, either isolated or in the setting of
associated fracture. Because forward surgical units do not
have a vascular surgeon available, orthopaedic surgeons must
be comfortable with temporary shunting of dysvascular limbs
before evacuation to a higher level of care, where definitive
vascular reconstruction can occur. The technique for place-
ment of a vascular shunt after obtaining proximal and distal
control involves choosing a shunt with a diameter that closely
matches the native vessel, thrombectomy of the artery to
obtain brisk back-bleeding, instillation of heparinized saline
proximally and distally, followed by placement of the shunt
into the native vessel to a distance of 1.5–2 cm.40,41 Although
venous extremity injuries can be ligated in damage control
situations, venous shunts, along with the liberal use of fas-
ciotomies, reduce the risk of secondary thrombosis of the
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arterial shunt and the development of acute compartment syn-
drome (ACS).40 Shunted limbs associated with fracture
should always have a spanning external fixator placed to
stabilize the limb and prevent shunt thrombosis or dislodge-
ment during evacuation.
Acute Compartment Syndrome
Orthopaedic surgeons must also be aware of the high
incidence of ACS seen after combat-related extremity trauma,
even in the absence of a tibia fracture. If clinical suspicion for
ACS exists or is supported by injury mechanism in the
obtunded or intubated patient, prophylactic fasciotomies
should be performed emergently before evacuation.42 Because
the consequences of missed compartment syndrome far out-
weigh the risks of an unnecessary fasciotomy and the potential
for lengthy evacuations, combat surgeons are encouraged to
liberally perform fasciotomy in the forward environment.
Despite recent reports indicating that 4-compartment fascioto-
my is safely performed through a single lateral incision, it is
recommended for austere deployed environments to continue
the use of 2 incisions to avoid the risk of an incomplete deep
posterior compartment release.43,44
Acute Management of Pelvic Ring Injuries
Early identification of unstable pelvic ring injuries
remains a critical aspect of the primary survey downrange.
Once diagnosed, application of a well-positioned binder or
sheet over the greater trochanters serves as an immediate
maneuver capable of reducing the pelvic volume and stabiliz-
ing the pelvis, which aids in clot formation.45,46 Sheets afford
the benefit of widespread availability, can be cut for vascular
access, and can be left in place without impeding access for
emergent laparotomy, preperitoneal pelvic packing, or conver-
sion to external fixation. Surgeons in far forward environments
should be prepared to perform pelvic packing when hemody-
namic instability and shock persist despite mechanical stabili-
zation of the pelvis and aggressive attempts at resuscitation;
invasive angiography is unavailable in austere environments
and far forward surgical units. Preperitoneal packing can be
performed quickly through a small suprapubic incision. After
external fixator stabilization of the pelvis, laparotomy sponges
are packed into the traumatic cavity of the true pelvis. These
create a tamponade effect adequate to control bleeding and
provide for clot formation.47 When an external fixator is placed
in the deployed setting, the iliac crest is used with at least 2
pins placed per side; intraoperative fluoroscopy is not available
to guide pin placement in other areas of the hemipelvis.
Extrapolating Military Experience to Civilian
Applications
The advances described above may have had their
genesis and greatest application in the combat setting, but
these techniques have been adopted where appropriate in the
civilian sphere and reflect a beneficial bidirectional evolution in
trauma care. The earlier use of blood products with a 1:1:1 ratio
has become standard in many civilian centers, and tourniquets
are now routinely used by civilian emergency providers as
well; effective tourniquet application was credited with saving
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J Orthop Trauma  Volume 30, Number 10 Supplement, October 2016
TABLE 1. Resuscitation and Treatment of Shock—Tips and
Pearls
1. It is easier to prevent shock than it is to treat it. Hemorrhage must be
identified early and addressed as soon as possible.
2. MT protocols should be tailored to the individual medical unit, location,
and resources. Identify your assets and availability early to prepare for
triage during mass casualty scenarios.
3. External fixator components are cheap and widely available in austere
environments and should be used liberally for temporizing management of
open and closed long bone fractures and pelvic ring injuries before
evacuation to a higher level of care.
lives during the Boston Marathon bombing.48–51 This serves as
a reminder to civilian providers that complex extremity war-
type wounds and mass casualty situations may occur in their
communities, as events such as the San Bernadino shootings
and the multi-centric Paris attack with bombs and high-velocity
assault weapons have shown.52 In addition to the time honored
military practice of triage, the more recent principles of resus-
citation, hemorrhage control, and damage control orthopaedics
are valuable lessons for any orthopaedic surgeon-military or
civilian (Table 1).
CONCLUSIONS
Advances in the care of polytraumatized patients with
extremity injuries continue to occur as a result of modern
challenges faced on the battlefield. Hemorrhage control as
a result of proven and emerging resuscitative strategies and
surgical techniques has led to a greater likelihood of survival
after devastating bodily injury than at any prior point in our
military’s history. Future research will need to identify which
of these strategies are most effective on the modern battle-
field, one where surgical units must be lighter, smaller, and
more mobile to support the changing scope of military com-
bat operations. These lessons will continue to be applicable to
civilian settings, particularly when addressing complex open
injuries, natural disasters, and mass casualty events.
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