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The authors would like to thank the correspondents for their interest in our manuscript and for their interesting comments.

Dr Wiles discussed the relative amount and quality of evidence regarding damage control resuscitation – and permissive hypotension in particular. We would agree that large robust randomised controlled trials are lacking. However in all clinical trials of fluid replacement during the acute bleeding phase in trauma patients, outcomes have been better or equivalent with lower volume resuscitation. It is difficult to recommend high volume/high pressure resuscitation strategies in the light of this evidence.

Dr Wiles also discussed the role of permissive hypotension in traumatic brain injury and the recommended blood pressure thresholds in published guidelines. Importantly here the recommended thresholds come from observational studies and to our knowledge there have been no clinical trials of blood pressure targets during active haemorrhage in patients with combined traumatic brain injury. Observational studies tell us that patients with lower blood pressures do worse than those with normal blood pressures. This is, to a certain extent, obvious – patients with TBI and haemorrhage are likely to do worse than those with isolated TBI. These studies cannot tell us that high volume fluid resuscitation will improve these outcomes. Experimental studies would suggest they may not. The Brain Trauma Foundation guidelines do not state whether their blood pressure targets are to apply during active haemorrhage [1].

Severely injured blunt trauma patients with traumatic brain injury and active bleeding present a tremendous challenge with no clear evidence base upon which to plan resuscitation. Like NICE with its prehospital fluid resuscitation guidelines, the authors believe that the risks of early high volume resuscitation outweigh the benefits. Like Dr Wiles we would welcome a larger research base upon which to work from and acknowledge that the definite answer to the question posed remains unknown.

Dr Chitnavis highlights the discrepancies between the findings of our review and current ATLS and PHTLS teaching. Both of these courses, by necessity, are conservative in their approach to changing clinical practice. As they have to cover a global population training base they must ensure that the direction of travel is correct, unlikely to change significantly and supported be a reasonable body of evidence. The 9th edition of the ATLS manual [3], recently published, is closely aligned to the principles of damage control resuscitation. Balanced resuscitation is emphasised and the term ‘aggressive resuscitation’ has been removed. Recommended volumes of crystalloid have been reduced and the early use of blood and blood products is highlighted.

Once again the authors would like to thank the correspondents for contributing to the discussion on this important topic.

1. Brain Trauma Foundation, American Association of Neurological Surgeons (AANS), Congress of Neurological Surgeons (CNS), AANS/CNS joint Section on neurotrauma and Critical Care. Guidelines for the management of severe traumatic brain injury, 3rd edition. J Neurotrauma 2007;24:S1-106

2. Pre-hospital initiation of fluid replacement therapy in trauma. Technology appraisal 74. January 2004.

3. Advanced Trauma Life Support for Doctors. 9th edition, 2012. Chicago, Il. American College of Surgeons Committee on Trauma, 1997.

Competing interests: KB has received unrestricted research funding from Octapharma and TEM, and has consulted for Haemonetics and Sangart. TH and RT – none declared.

Tim Harris, Emergency physician

Dr Rhys Thomas, Prof Karin Brohi

QMUL and Barts Health NHS Trust, Whitechapel road, Whitechapel, E11BB

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The authors of this review strongly advocate the practice of damage control resuscitation (DCR) and permissive hypotension in the multiply injured patient, but there seems to be a paucity of evidence to support this assertion.

Much of the evidence for permissive hypotension has been extrapolated from data from animal studies. The largest human study cited by the authors in the review [1] did suggest some benefit from a delayed resuscitation strategy, but there important caveats. The study population all suffered penetrating injuries, whilst blunt trauma is far more common in UK trauma cases. In addition, 70 of the 598 patients died before reaching the operating theatre and there is no information about the cause of these deaths and 22 of the 260 patients in the delayed resuscitation group actually received early fluids. Human studies involving blunt trauma victims have failed to demonstrate any mortality benefit for damage control resuscitation strategies [2,3].

The potential for harm using DCR in the head inured patient should not be underestimated. The authors acknowledge that a single episode of hypotension in the brain injured patient is associated with a doubling in mortality although the references are incorrect [4]. The Brain Trauma Foundation therefore recommends avoiding a systolic blood pressure of < 90 mmHg in traumatic brain injury [5]. The European Brain Injury Consortium and the Association of Anaesthetists recommend much higher targets with mean arterial blood pressures of > 90 and > 80 mmHg respectively [6,7]. Brain injury is common in polytrauma patients and remains the leading cause of death [8].

Until further research has been undertaken that specifically examines the risks and benefits of DCR in blunt trauma and traumatic brain injury, DCR should be practiced with caution by those involved in trauma care in the UK.

1.Bickell WH, Wall MJ, Jr., Pepe PE et al. Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries. New Engl J Med 1994; 331:1105-09.
2.Turner J, Nicholl J, Webber L et al. A randomized controlled trial of prehospital intravenous fluid replacement therapy in serious trauma. Health Technol Assess 2000; 4:1-57.
3.Dula D, Wood G, Craig G et al. Use of prehospital fluids in hypotensive blunt trauma patients. Prehosp Emerg Care 2002; 6:417-20.
4.Chesnut RM, Marshall LF, Klauber MR, et al. The role of secondary brain injury in determining outcome from severe head injury. J Trauma 1993; 34: 216–22.
5.Brain Trauma Foundation, American Association of Neurological Surgeons (AANS), Congress of Neurological Surgeons (CNS), AANS/CNS Joint Section on Neurotrauma and Critical Care. Guidelines for the management of severe traumatic brain injury, 3rd edition. J Neurotrauma 2007; 24: S1–106.
6.Maas AI, Dearden M, Teasdale GM, et al. EBIC-guidelines for management of severe head injury in adults. European Brain Injury Consortium. Acta Neurochir (Wien) 1997; 139: 286–94.
7.The Association of Anaesthetists of Great Britain and Ireland. Recommendations for the Safe Transfer of Patients with Brain Injury. London: The Association of Anaesthetists of Great Britain andIreland, 2006
8.Faist E,Baue AE,Dittmer H,Heberer G. Multiple organ failure in polytrauma patients. J Trauma 1983; 23:775-87.

Competing interests: None declared

Matthew D Wiles, Consultant Neuroanaesthetist

Sheffield Teaching Hospitals NHS Foundation Trust, Glossop Road, Sheffield. S10 2JF.

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In support of hypovolaemic resuscitation of trauma patients, the authors (1) cite NICE guidance stipulating that 'no fluid be administered in the pre-hospital resuscitation phase if a radial pulse can be felt, or for penetrating trauma if a central pulse is palpable'.

Such advice runs contrary to current teaching on the management of haemorrhagic shock in both Prehospital (2) and Advanced Trauma Life Support (3) manuals, both of which advocate initial fluid therapy.

The authors' management of severely injured patients with 'permissive hypovolaemia' is not commonly practised.

Their review states that a 3:1 ratio of crystalloid volume replacement for blood loss was promoted in the 1960s and 1970s. I would like to remind them that such advice is still part of current ATLS teaching. (3)

What should we be doing for haemorrhagic shock in trauma?

Jai Chitnavis
Consultant Trauma and Orthopaedic Surgeon

1. Harris T, Rhys Thomas GO, Brohi K. Early fluid resuscitation in severe trauma. BMJ 2012; 345.
2. Pre-hospital Trauma Life Support. Sixth Edition. 2007. Mosby Elsevier. Prehospital Trauma Life Support Committee of the National Association of Emergency Medical Technicians in Cooperation with The Committee on Trauma of The American College of Surgeons.
3. Advanced Life Support for Doctors. Student Manual. Eighth Edition.2008. American College of Surgeons Committee on Trauma.

Competing interests: None declared

Jai Chitnavis, Honorary Consultant Trauma and Orthopaedic Surgeon

Cambridge University Hospitals NHS Trust, Cambridge, UK. CB22QQ

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