Acute resuscitation of the unstable adult trauma patient: bedside diagnosis and therapy.

Traumatic injury remains the leading cause of potentially preventable death in Canadians under age 40 years. Although only a minority of patients present with hemodynamic instability, these patients have a significant chance of dying. The causes of instability must be recognized and corrected quickly by using a systematic approach. To allow key supportive interventions to be undertaken swiftly, it is more important to identify and prioritize systemic compromise than to confirm specific diagnoses. Most potentially preventable trauma death relates to airway obstruction, hemopneumothorax, intracranial hemorrhage and intracavitary bleeding. Definitive airway control should be assured as a first priority. Hemopneumothoraces are typically addressed by chest tube insertion, although thoracic exploration will occasionally be urgently required. Hemorrhage control is much more important than fluid resuscitation and mandates the earliest possible definitive management. Unstable patients nearing physiological exhaustion require abbreviated or "damage-control" surgical tactics. This should be recognized early in the resuscitation rather than late in an operative procedure. The management of expanding intracranial hemorrhage requires optimization of oxygenation, ventilation and circulatory support while urgent CT and expert neurosurgical care are provided. Polytrauma presenting with head injury challenges the most developed of trauma systems, necessitating thoughtful prioritization of care and taking into consideration local capabilities. Bedside trauma sonography is an evolving tool that complements the physical examination during an initial survey. Future breakthroughs in trauma resuscitation may involve procoagulant medications, imaging technology, circulatory assist techniques and the use of inflammatory modulators. The greatest future challenge in trauma care, though, will be the provision of basic organized resuscitative care to the global community.