TRAUMA TRIAD OF DEATH: HYPOTHERMIA, ACIDOSIS AND COAGULOPATHIES

Jeff Solheim MSN RN-BC CEN CFRN FAEN

I. Hypothermia

Classification Traditional Trauma Patient

Mild < 35 - 32°C 35 - 34°C
Moderate 32 - 28°C 34 - 32°C
Severe < 28°C < 32°C

A. Predisposing factors:
1. Heat loss in the field Gregory et al found
2. Resuscitation maneuvers that hypothermia
developed at some
3. Injury severity (most heat loss with injuries to the
point in 57% of
extremities, pelvis, abdomen, and large blood vessels) trauma patients
4. Elevated blood alcohol levels studied, with the
5. Exposure of body cavities during surgery greatest temperature
6. Use of anesthetics/paralytics loss occurring in the
7. Impaired thermogenesis (tissue oxygen debt, hypoxic Emergency
hypothalamus Department
8. Transfusion
9. Age

B. Effects of Hypothermia

Cardiovascular  Mild hypothermia -  sympathetic activity and catecholamines

System (vasoconstriction, tachycardia, increased cardiac output, atrial and
ventricular arrhythmias)
 Severe hypothermia -  heart rate and cardiac output, increasing
vascular resistance)
 < 28°C – depression of myocardial contractility
 <25°C – risk of ventricular fibrillation
Pulmonary System   respiratory rate which becomes increasingly depressed with
worsening hypothermia
 Pulmonary edema and excessive production of bronchial secretions
with rewarming
Central Nervous  Progressive depression of level of consciousness
System   Cerebral blood flow
Renal System  Increased urinary flow despite  GFR and blood flow to the kidney
Electrolyte and acid-   potassium levels
base equilibrium  Acidosis
TRAUMA TRIAD OF DEATH: HYPOTHERMIA, ACIDOSIS AND COAGULOPATHIES
Jeff Solheim MSN RN-BC CEN CFRN FAEN

Gastrointestinal and  Mild ileus

endocrine system  Depressed hepatic function
 Hyperglycemia
Metabolism   metabolic rate   O2 uptake,  CO2 production and  solubility
of CO2
Hematological   blood viscosity
system   hct during rewarming
 Inhibition of clotting cascade
 Thrombocytopenia
 Left shift of the oxyhemoglobin dissociation curve

THE BOTTOM LINE: Hypothermia has detrimental effects on the outcome of severely injured
patients. The lower the temperature is allowed to drop, the higher mortality climbs with 100%
mortality at temperatures of 32°C.

C. Rewarming strategies:
1. Passive external measures:
a. Remove blood or saline soaked dressings and blankets
b. Increase ambient room temperature
c. Decrease air flow over the patient
2. Active external measures
a. Fluid circulating, convective air and aluminum space blankets
b. Overhead radiant warmers
c. Head covering
d. Avoid covering exposed bowel with saline moistened towels in the
OR (dry towels or plastic bags are superior).
3. Active internal measures
a. Humidified and warmed ventilator circuits
b. Heated body cavity lavage (gastric, bladder, colonic, pleural)
c. Heated IV fluids
d. Continuous arteriovenous rewarming (CAVR)
e. Damage Control Surgical Intervention
II. Acidosis
A. Causes
a. Inadequate tissue perfusion leads to metabolic lactic acidosis
b. Multiple blood transfusions
c. Excessive normal saline administration
d. Hypoventiation
B. Deleterious effects of acidosis
1. Impaired renal and hepatic blood flow
2. Decreased cardiac contractility
3. Vasodilation leading to hypotension
4. Increased risk for ventricular dysrhythmias and bradycardia.
5. Prolonged clotting times and increased bleeding times.
C. The bottom line
1. Patient’s with an average serum pH of 7.29 have the highest survival
potential.
2. Serum pH below 7.2 causes deleterious effects on cardiovascular and
coagulation.
TRAUMA TRIAD OF DEATH: HYPOTHERMIA, ACIDOSIS AND COAGULOPATHIES
Jeff Solheim MSN RN-BC CEN CFRN FAEN

C. Treatment considerations
1. Aimed at correcting hypoperfusion
a. Assure adequate resuscitation volume
b. Transfusions
c. Resuscitate to appropriate end-points
i. Arterial pH
ii. Base deficit
iii. Lactate levels
iv. Etc.
III. Coagulopathies
A. Causes
a. Primary causes – due to activation of the inflammatory system and activation
of coagulation factors
b. Secondary causes
i. Dilution
ii. Consumption
c. Hypothermia
d. Blood loss
e. Acidosis
TRAUMA TRIAD OF DEATH: HYPOTHERMIA, ACIDOSIS AND COAGULOPATHIES
Jeff Solheim MSN RN-BC CEN CFRN FAEN

B. Treatment
a. Permissive Hypotension
b. Local modalities
c. Antifibrinolytics
d. Recombinant activated factor VII (rVIIa)
e. 1:1:1 Resuscitation
f. Whole blood resuscitation

References

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