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BACKGROUND Tranexamic acid (TXA) administration is recommended in severely injured trauma patients. We examined TXA administration, admission fibrinolysis phenotypes, and clinical outcomes following traumatic injury and hypothesized that TXA was associated with increased multiple organ failure (MOF). METHODS Two-year, single-center, retrospective investigation. Inclusion criteria were age ≥ 18 years, Injury Severity Score (ISS) >16, admitted from scene of injury, thromboelastography within 30 min of arrival. Fibrinolysis was evaluated by lysis at 30 min (LY30) and fibrinolysis phenotypes were defined as: Shutdown: LY30 ≤ 0.8%, Physiologic: LY30 0.81-2.9%, Hyperfibrinolysis: LY30 ≥ 3.0%. Primary outcomes were 28-day mortality and MOF. The association of TXA with mortality and MOF was assessed among the entire study population and in each of the fibrinolysis phenotypes. RESULTS Four hundred twenty patients: 144/420 Shutdown (34.2%), 96/420 Physiologic (22.9%), and 180/410 Hyperfibrinolysis (42.9%). There was no difference in 28-day mortality by TXA administration among the entire study population (P = 0.52). However, there was a significant increase in MOF in patients who received TXA (11/46, 23.9% vs 16/374, 4.3%; P

Anesthesiologists will continue to be recognized as airway experts and other specialties will need ongoing access to the clinical volume available in the OR setting when looking for opportunities to meet their residents’ and fellows’ airway management training needs. At the same time, critical care, EM, and other physicians have acquired an ever-expanding array of skills and experience managing the airways of critically ill and injured patients. When considering the needs of nonanesthesiologist trainees coming to our domain, it is essential to recognize the differences inherent in practicing outside of the OR and to incorporate those aspects of airway management considerations into training paradigms. This should be viewed as an opportunity to work toward a more universal approach to training and airway management in our individual institutions incorporating a multidisciplinary approach to education and clinical activities. Within this structure, the evolving aspects of mastery learning or milestone achievement require us to work toward establishing more objective measures of competency and proficiency wherever possible. This includes a more rigorous application of SBT-directed at mastery learning and deliberate practice with a focus not only on technical skills but also NTS. The location for and leadership of the training likely is less important than the individuals involved in program development. A focus on VL-based training for early learners appears to be supported by the data but must be balanced against the technical and environmental challenges. As noted by Straker [107] in an editorial looking at airway management in the twenty-first century, “Airway management is no longer synonymous with only endotracheal intubation—it is finally recognized as a complex array of skills taking years to master to provide the utmost in terms of patient safety.” True mastery requires years of experience and hundreds of patient encounters. In the meantime, anesthesiologists need to figure out how best to support the goal of improving airway management training to move all trainees to the point of proficiency and beyond.

Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has spread worldwide. During the ongoing COVID-19 epidemic, most hospitals have postponed elective surgeries. However, some emergency surgeries, especially for trauma patients, are inevitable. For patients with suspected or confirmed COVID-19, a standard protocol addressing preoperative preparation, intraoperative management, and postoperative surveillance should be implemented to avoid nosocomial infection and ensure the safety of patients and the health care workforce. With reference to the guidelines and recommendations issued by the National Health Commission and Chinese Society of Anesthesiology, this article provides recommendations for anesthesia management of trauma and emergency surgery cases during the COVID-19 pandemic.

Anesthesiologists managing traumatically injured patients are seeing an increased incidence of patients on direct oral anticoagulants (DOACs). Management of these patients requires an understanding of the pharmacology and pharmacodynamics of these agents in the perioperative setting. With limited reversal options, what are the best options for managing these often complex patients? The reversal agent for dabigatran, idarucizumab, can be useful in the setting of severe hemorrhage. The role of prothrombin complex concentrates is less clear but continues to be recommended in most published guidelines. Management of the DOAC-associated bleeding in the trauma patient requires a stepwise approach taking the severity of bleeding and urgency of surgery/procedures into consideration as well as hemodynamic stability and mortality risk. Frequently, a conservative approach that allows for a drop in plasma DOAC levels is the best option for the patient with minimal to no bleeding. The use of specific reversal agents is limited to dabigatran, but other agents are on the horizon.

Despite over a half-century of recognizing fibrinolytic abnormalities after trauma, we remain in our infancy in understanding the underlying mechanisms causing these changes, resulting in ineffective treatment strategies. With the increased utilization of viscoelastic hemostatic assays (VHAs) to measure fibrinolysis in trauma, more questions than answers are emerging. Although it seems certain that low fibrinolytic activity measured by VHA is common after injury and associated with increased mortality, we now recognize subphenotypes within this population and that specific cohorts arise depending on the specific time from injury when samples are collected. Future studies should focus on these subtleties and distinctions, as hypofibrinolysis, acute shutdown, and persistent shutdown appear to represent distinct, unique clinical phenotypes, with different pathophysiology, and warranting different treatment strategies.

Trauma anesthesiologists are uniquely juxtaposed with the multidisciplinary trauma team, serving both an administrative role in preparing the operating room (OR) and allocating resources for resuscitation, and a direct patient care role, providing definitive airway management and advanced resuscitation. Trauma anesthesiologists must have an intimate understanding regarding mechanisms of injury, appropriate diagnostic modalities, and current practices regarding OR versus emergency department or radiology suite (IR) resuscitation. In this review, current practices regarding assessment and triage, mechanisms of injury, and the concepts of surgical, orthopedic, and radiology “damage control” approaches to the severely injured trauma patient are discussed.

The role of radiographic imaging and ultrasound (US) in decision-making during the early management of the polytrauma patient has increased significantly in the last decade based on technological advancements and ongoing research. With the introduction of faster and more capable computed tomography scanners as well as portable US machines, individuals responsible for the care of the trauma patient have more information than ever to guide perioperative care and operative decisions. This has led to the implementation of Damage Control Radiology (DCRad) in the early resuscitation and treatment of these patients. In this review, we focus on the current literature surrounding applications of US and other radiographic imaging in the early management of the trauma patient. This includes reviews of the Focused Assessment with Sonography in Trauma (FAST) and Extended-FAST (E-FAST) exams with an emphasis on their applicability, sensitivity, and specificity in the setting of blunt and penetrating trauma as well as their ability to predict the need for an operative intervention. Additionally, we will briefly review the role of US for airway management, and vascular access. Relevant to anesthesiologists managing patients with potential cervical spine injury, we will also review recommendations regarding radiographic clearance of the cervical spine in the obtunded patient. Finally, we will discuss early detection and management of patients with blunt cerebrovascular injury in the early perioperative period.

Intracranial hypertension (ICH) and hyperthermia are common after traumatic brain injury (TBI) and associated with worse neurological outcomes. This study sets out to determine the combined power of temperature and intracranial pressure (ICP) for predicting neurologic outcomes and prolonged length of stay (LOS) following severe TBI.High resolution (every 6 seconds) temperature and ICP data were collected in adults with severe TBI from 2008-2010. Temperatures were plotted against concurrent ICP and divided based on breakpoints (Temperature:36, 36-38.5 or38.5 °C, ICP:20, 20-30 or30 mmHg). The percentage of time spent in each section, as well as several pooled unfavourable conditions (hyperthermia ± ICH), were then evaluated for predictive value for ICU-LOS 7 days and short-term (6 months) vs. long-term (6 months) dichotomized neurologic outcomes.Fifty patients were included for analysis with severe TBI. Evaluation of the area under the operating receiver curve (AUC) showed significant periods of fever and high ICP (30 mmHg) had a strong association with poor long-term neurological outcomes (Day 3, AUC = 0.71, p = 0.04) and were higher than either condition alone. ICU-LOS 7 days was increased when hyperthermia and/or ICH remained uncontrolled by Day 5 (AUC = 0.82, p = 0.02).Hyperthermia combined with ICH were shown to be significant prognostic indicators of future poor neurologic outcomes in patients with severe traumatic brain injury.

Background:Although the use of an anesthesiology “airway” rotation to train the nonanesthesiologist is commonly employed, little data exist on the utility, clinical exposure, and outcomes of these programs.Methods:A prospectively collected observational dataset of airway procedures completed by trainees in a 4-week, anesthesiology-based, airway rotation at an academic, level-1 trauma center from July 2010 to September 2012 was reviewed. Prospectively defined data points were collected through an online data tool and included patient demographics, location, date, best laryngoscopic view, and attempt details. At the authors’ institution, an attending trauma anesthesiologist is present for all intubation attempts. The primary outcome was first-attempt success.Results:A total of 4,282 self-reported, airway procedures were identified. The median number of procedures performed was 50.4 ± 13.2 (range, 20 to 93; 25th quartile = 41; 75th quartile = 57). Multivariate logistic regression analysis modeling of first-attempt success rate identified two independent predictors of success: rotation week (odds ratio, 1.42; 95% CI, 1.32 to 1.61; P < 0.0001) and number of previous intubation attempts before rotation (odds ratio, 1.23; 95% CI, 1.03 to 1.46; P = 0.02. In addition, the percentage of cases with a self-reported laryngoscopic grade 1 view increased significantly from 61 to 74% (P = 0.015) from week 1 to week 4 of the rotation.Conclusions:An anesthesiology-based program for airway training of nonanesthesiologists demonstrates improved self-reported, perceived first-attempt success over the course of training with improved ability to visualize glottic structures.

Many resuscitation scenarios include the use of emergency intubation to support injured patients. New video-guided airway management technology is available, which may minimize the risk to patients from this procedure.This was a controlled clinical trial conducted in the trauma receiving unit in a university-affiliated urban hospital in which 623 consecutive adult patients requiring emergency airway management were prospectively randomized to intubation with either the direct laryngoscope (DL) or the GlideScope video laryngoscope (GVL) device.The primary outcome was survival to hospital discharge. There was no significant difference in mortality between the GVL group (28 [9%] of 303) and the DL group (24 [8%] of 320) (p = 0.43) for all patients. Within a smaller cohort identified retrospectively, there was a higher mortality rate seen in the subgroup of patients with severe head injuries (head Abbreviated Injury Scale [AIS] score3) who were randomized to intubation with GVL (22 [30%] of 73) versus DL (16 [14%] of 112) (p = 0.047). Among all patients, median intubation duration in seconds was significantly higher for the GVL group (median, 56; interquartile range, 40-81) than for the DL group (median, 40; interquartile range, 24-68) (p0.001). Among those with severe head injuries, median intubation duration in seconds was also significantly higher for the GVL group (median, 74) than for the DL group (median, 65) (p0.003). Correspondingly, this group also experienced a greater incidence of low oxygen saturations of 80% or less (27 [50%] of 54 for the GVL group and 15 [24%] of 63 for the DL group; p = 0.004). There were no significant differences between the two groups in first-pass success (80% for GVL and 81% for DL, p = 0.46).Use of the GlideScope did not influence survival to hospital discharge among all patients and was associated with longer intubation times than direct laryngoscopy. Among the video laryngoscope cohort, a smaller subgroup of severe head injury trauma patients identified retrospectively seemed to be associated with a greater incidence of hypoxia of 80% or less and mortality.

Recent healthcare legislation, financial pressures, and regulatory oversight have increased the need to create improved mechanisms for performance measurement, quality management tracking, and outcomes-based research. The Anesthesia Quality Institute (AQI) has established the National Anesthesia Clinical Outcomes Registry (NACOR) to support these requirements for a wide-range of customers including individual anesthesiologists, anesthesia practices, hospitals, and credentialing agencies. Concurrently, the availability of increased digital sources of healthcare data make it possible to capture massive quantities of data in a more efficient and cost-effective manner than ever before. With NACOR, AQI has established a user-friendly, automated process to effectively and efficiently collect a wide-range of anesthesia-related data directly from anesthesia practices. This review will examine the issues guiding the evolution of NACOR as well as some potential pitfalls in its growth and usage.

This document was developed through the collaborative efforts of the Society of Critical Care Medicine, the American College of Chest Physicians, and the Association of Organ Procurement Organizations. Under the auspices of these societies, a multidisciplinary, multi-institutional task force was convened, incorporating expertise in critical care medicine, organ donor management, and transplantation. Members of the task force were divided into 13 subcommittees, each focused on one of the following general or organ-specific areas: death determination using neurologic criteria, donation after circulatory death determination, authorization process, general contraindications to donation, hemodynamic management, endocrine dysfunction and hormone replacement therapy, pediatric donor management, cardiac donation, lung donation, liver donation, kidney donation, small bowel donation, and pancreas donation. Subcommittees were charged with generating a series of management-related questions related to their topic. For each question, subcommittees provided a summary of relevant literature and specific recommendations. The specific recommendations were approved by all members of the task force and then assembled into a complete document. Because the available literature was overwhelmingly comprised of observational studies and case series, representing low-quality evidence, a decision was made that the document would assume the form of a consensus statement rather than a formally graded guideline. The goal of this document is to provide critical care practitioners with essential information and practical recommendations related to management of the potential organ donor, based on the available literature and expert consensus.

Purpose of review Death from exsanguinating hemorrhage remains a priority in the management of combat casualties and civilian trauma patients with truncal and junctional injuries. Appropriate use of hemostatic agents and dressings in the prehospital setting may allow for earlier control and an improved survival rate. Recent findings Third-generation chitosan-based hemostatic agents and dressings appear to be equally efficacious to the dressing currently deployed by the US military forces in the management of hemorrhage not amenable to tourniquet placement. Unfortunately, a lack of clinical trials places a heavy reliance on anecdotal reports and laboratory studies in agent selection and application. Summary Efficacy of currently available hemostatic agents and dressings appears to have plateaued in recent years although new agents and delivery mechanisms under development may improve control in cases of severe hemorrhage.

Supplemental Digital Content is available in the text.

Critical Care Air Transport Teams (CCATTs) have evolved as a vital component of the U.S. Air Force's aeromedical evacuation system. Previous epidemiological research in this area is limited. The objective of this commentary is to highlight the importance of obtaining robust epidemiological data regarding patients transported by CCATTs. A limited epidemiological analysis was performed to describe CCATT patients transported during Operation Enduring Freedom and the waning months of Operation Iraqi Freedom. CCATT transports for the calendar year 2011 were examined as recorded in the U.S. Transportation Command Regulating and Command and Control (C2) Evacuation System database. As many as 290 CCATT primary patient transport records were reviewed. Of these, 58.6% of patients had multiple injuries, 15.9% of patients had traumatic brain injury, 7% had acute coronary syndromes, and 24.8% of all transports were for nonbattle-related injuries. The most common International Classification of Disease, 9th Edition, Clinical Modification coded injury was bilateral lower extremity amputation (40%). Explosive blasts were the top mechanism of injury for patients requiring CCAT. The distribution of injuries and illnesses requiring CCAT appear to have changed compared to previous conventional conflicts. Understanding the epidemiology of casualties evacuated by CCATT during modern warfare is a prerequisite for the development of effective predeployment training to ensure optimal outcomes for critically ill and injured warriors.

Although the use of an anesthesiology "airway" rotation to train the nonanesthesiologist is commonly employed, little data exist on the utility, clinical exposure, and outcomes of these programs.A prospectively collected observational dataset of airway procedures completed by trainees in a 4-week, anesthesiology-based, airway rotation at an academic, level-1 trauma center from July 2010 to September 2012 was reviewed. Prospectively defined data points were collected through an online data tool and included patient demographics, location, date, best laryngoscopic view, and attempt details. At the authors' institution, an attending trauma anesthesiologist is present for all intubation attempts. The primary outcome was first-attempt success.A total of 4,282 self-reported, airway procedures were identified. The median number of procedures performed was 50.4 ± 13.2 (range, 20 to 93; 25th quartile = 41; 75th quartile = 57). Multivariate logistic regression analysis modeling of first-attempt success rate identified two independent predictors of success: rotation week (odds ratio, 1.42; 95% CI, 1.32 to 1.61; P0.0001) and number of previous intubation attempts before rotation (odds ratio, 1.23; 95% CI, 1.03 to 1.46; P = 0.02. In addition, the percentage of cases with a self-reported laryngoscopic grade 1 view increased significantly from 61 to 74% (P = 0.015) from week 1 to week 4 of the rotation.An anesthesiology-based program for airway training of nonanesthesiologists demonstrates improved self-reported, perceived first-attempt success over the course of training with improved ability to visualize glottic structures.

During periods of peacetime, human patient simulation will provide hands-on training for military medical personnel for wartime-specific requirements. The Center for the Sustainment of Trauma and Readiness Skills (C-STARS), Baltimore and the R Adams Cowley Shock Trauma Center (STC) collaborated to create a jointly funded simulation center to support this need as well as training for civilian trauma programs. A 1200-sq ft area conveniently located in STC opened in February 2012 equipped with four dedicated trauma bays, course management software, and advanced digital audio-video recording capacities. The center contains additional space for storage, a control room, and adjacent debriefing/conference space to support both the C-STARS and STC training missions. To date, over 500 military trainees and several civilian programs have made use of the new center. Additional work under this program included the development of four military-specific, multi-patient scenarios. These scenarios supplemented the previous C-STARS curriculum to replicate a high-workload setting and support discussion of teamwork and leadership in a high-stress environment. Finally, the completed work included an assessment of debriefing modalities. Twenty-four Air Force medical teams were evaluated for clinical and behavioral performance during recorded, simulated trauma resuscitations to determine whether a structured briefing (plus-delta, PD) influenced subsequent performance as compared to a more reflective style of debriefing (debriefing with good judgment, DGJ). Video review of before-after performance following debriefing showed no change in behavioral or clinical performance related to the debriefing style. Clinical performance did improve slightly, most likely because of practice. Recommendations from this study include a preference for the PD style when primary training focus is on technical or procedural performance and DGJ when focus is on behavioral performance elements.

Recent healthcare legislation, financial pressures, and regulatory oversight have increased the need to create improved mechanisms for performance measurement, quality management tracking, and outcomes-based research. The Anesthesia Quality Institute (AQI) has established the National Anesthesia Clinical Outcomes Registry (NACOR) to support these requirements for a wide-range of customers including individual anesthesiologists, anesthesia practices, hospitals, and credentialing agencies. Concurrently, the availability of increased digital sources of healthcare data make it possible to capture massive quantities of data in a more efficient and cost-effective manner than ever before. With NACOR, AQI has established a user-friendly, automated process to effectively and efficiently collect a wide-range of anesthesia-related data directly from anesthesia practices. This review will examine the issues guiding the evolution of NACOR as well as some potential pitfalls in its growth and usage.

The stresses of flight create new and unique considerations for the inexperienced medical provider during their initial involvement in the air transport of sick and injured patients. Not only must constant attention be paid to the impact of these stresses on a patient’s condition but on proper equipment performance and the ability of the caregivers to deliver the best medical support possible. Anticipation and prevention of potentially serious complications by vigilant patient monitoring and initiation of therapy is the responsibility of the entire medical crew during air transport. Appropriate ground training and familiarization with approved equipment will provide the crew members with the best opportunities for success.

Objective The provision of sophisticated medical care in an austere environment is challenging. During and after a mass casualty event, it is likely that critical care services will be needed beyond an intensive care unit (ICU) setting. The objective of this article is to explore existing ICU care systems such as military aeromedical transport that may be applicable to disaster medicine and to providing critical care outside of an ICU setting. Results The U.S. Air Force Critical Care Aeromedical Transport (CCAT) Teams were developed in 1994 in response to an unmet military need for long-range air transport of critically ill and injured patients. This system has transported several thousand ICU patients and is an applicable model for the future development of extrahospital critical care capabilities needed during a disaster. We also discuss civilian aeromedical critical care systems, the types of medical devices used, and their applicability to disaster medical response. Conclusion The U.S. Air Force CCAT Team program, as well as many civilian critical care air ambulance services, provides a workable starting point for the development of disaster medical critical care response capabilities for disaster medical systems.

We evaluated the effects of anesthetics on neurologic outcome in a model of recoverable experimental spinal cord injury (SCI). Adult rats were implanted with various sizes of hygroscopic plastic material at the T12 spinal level to determine the dimensions that would produce a progressive neurologic deficit from which recovery could occur. Neurologic evaluation was conducted on an inclined plane, noting the maximum angle at which an animal was able to maintain orientation perpendicular to the longitudinal midline. Scores were statistically modeled for each group to develop profiles of neurologic deficits. Rats were subjected to a 4-h exposure to isoflurane, fentanyl/nitrous oxide, or ketamine 7 or 8 days postimplantation. Neurologic outcomes were compared to a SCI reference group which received no postimplant anesthesia. An animal weight/desiccated implant volume (Wa/Vi) ratio of 53 to 73 g/mm3 produced postimplant neurologic deficits which deteriorated to near maximum within 3 days, followed by a gradual improvement beginning at Day 8 and returning to near normal between 21 and 25 days. Final outcome was based on modeled ramp scores for each group and reported in degrees +/- SD: reference, 71.2 +/- 1.1; fentanyl/N2O, 70.4 +/- 0.3; isoflurane, 72.6 +/- 1.1; and ketamine, 64.9 +/- 0.6. The fentanyl group attained maximum recovery first (P > 0.05) but did not recover to a level different on the average from the reference group. The ketamine group demonstrated a poorer (P > 0.05) recovery level relative to the other anesthetic protocols.

OBJECTIVE To compare propofol, methohexital, and midazolam administered as titrated infusions for sedation during electrical cardioversion. DESIGN A prospective, randomized, single-blind comparative study. SETTING Coronary care unit in a military teaching hospital. PATIENTS Thirty adult patients with atrial fibrillation, atrial flutter, or paroxysmal supraventricular tachycardia. Each patient required electrical cardioversion. Patients were randomized to receive one of the three study drugs. Ten patients composed one drug group. MEASUREMENTS AND MAIN RESULTS Demographic variables were similar between groups. Patients were randomized to receive propofol (10 mg/mL), methohexital (5 mg/mL), or midazolam (0.5 mg/mL) administered at 10 mL/min until the patients failed to follow verbal commands and demonstrated a degradation of the lid response to stimulation. Dose requirements (mean +/- SD) were propofol 1.69 +/- 0.46 mg/kg, methohexital 1.07 +/- 0.34 mg/kg, and midazolam 0.16 +/- 0.06 mg/kg. Hemodynamic assessment at baseline, after induction, after cardioversion, and at recovery demonstrated no difference in mean arterial pressure between the three groups. The time to awakening was significantly prolonged in the group that received midazolam (33 +/- 11 mins, p < .05) as compared with the times of the groups that received propofol (11 +/- 4 mins) and methohexital (9 +/- 3 min). Side-effects were similar between groups, with the exception of an increase in pain on injection with propofol and an increased frequency of confusion in those patients receiving midazolam. Recall of the electrical discharges at one hour after the procedure occurred in two patients in the propofol group. In both cases, there were technical problems which caused the duration of the procedure to extend into the anticipated recovery period. Unit dose costs at our institution for a 70-kg patient are: methohexitol, $3.14 (500-mg bottle); medazolam, $14.88 (5-mg vials x 3); and propofol, $6.60 (200-mg ampule). CONCLUSIONS All three drugs are acceptable choices for use during elective direct-current cardioversion. Titration of the agent results in a total drug dose which is usually less than the typical induction dose. There were no significant differences in the hemodynamic actions of these drugs at any time interval. Both propofol and methohexital proved superior in their ability to provide a more rapid anesthetic onset and recovery as compared with midazolam. Propofol offers the advantage of requiring no premixing or dilution, and it is not a controlled substance, although it does result in more pain on injection.

This review is designed to define and update the mechanisms and implications of Renin-Angiotensin system (RAS) activation, as well as the mechanisms and goals of RAS blockade, both in and outside of the operating room. In this way we hope to put into perspective how the RAS fits into the scheme of hemodynamic responses perioperatively and the potential manipulations we have at our disposal for the control of these responses

Teamwork training is critical for patient safety and has been advocated for widespread application in many settings. A key challenge for evaluating teamwork training is measurement. Despite much effort, the team performance instruments reported thus far suffer from a variety shortcomings that prevent their wide application in assessing teams in real settings. Based on review of video recorded trauma team activities in real patient care, a multi-disciplinary research team developed an instrument based on observable behaviors (UMTOP). A set of video clips were reviewed by 6 subject matter experts who were requested to provide “descriptors” about the observed team activities. The 167 collated descriptors were combined to a reduced list, which was then sent to the subject matter experts for revision. The revised list was then categorized into 5 areas of team performance (task and clinical performance, leadership organization, teamwork organization, social environment, sterile precaution). UMTOP was developed to be a tradeoff among four criteria: ease of use, reliability, usefulness for team performance feedback, and speed of scoring. An initial assessment of reliability was conducted with surgeon and nursing reviewers.

Background Care of the polytrauma patient does not end in the operating room or resuscitation bay. The patient presenting to the intensive care unit following initial resuscitation and damage control surgery may be far from stable with ongoing hemorrhage, resuscitation needs, and injuries still requiring definitive repair. The intensive care physician must understand the respiratory, cardiovascular, metabolic, and immunologic consequences of trauma resuscitation and massive transfusion in order to evaluate and adjust the ongoing resuscitative needs of the patient and address potential complications. In this review, we address ongoing resuscitation in the intensive care unit along with potential complications in the trauma patient after initial resuscitation. Complications such as abdominal compartment syndrome, transfusion related patterns of acute lung injury and metabolic consequences subsequent to post-trauma resuscitation are presented. Methods A non-systematic literature search was conducted using PubMed and the Cochrane Database of Systematic Reviews up to May 2012. Results and conclusion Polytrauma patients with severe shock from hemorrhage and massive tissue injury present major challenges for management and resuscitation in the intensive care setting. Many of the current recommendations for “damage control resuscitation” including the use of fixed ratios in the treatment of trauma induced coagulopathy remain controversial. A lack of large, randomized, controlled trials leaves most recommendations at the level of consensus, expert opinion. Ongoing trials and improvements in monitoring and resuscitation technologies will further influence how we manage these complex and challenging patients.