Part A:
Trauma stands to be among the major health hazards, over the years most cases of death have been attributed to this pandemic. Shockingly, is primarly the among  the leading causes of death among young adults and teenagers globally. In the urban areas road traffic carnages remains the leading cause of trauma in urban areas, stirring over 3000 deaths occurring on a daily basis. 85% of these deaths occur in middle and low-income states and mostly as a result of a secondary shock to hemorrhage. The paper navigates and shows how hemorrhagic shock is slightly higher than the years dating before 2000 and in some studies further strategies also need to be put in place to reduce further mortality due trauma needs to be explored.
Keywords shock; Haemorrhagic; Mortality; Road traffic injury; Survivors
Haemorrhagic shock is defined the inadequate delivery of nutrients and oxygen to body tissues leading to a decrease in circulating volume due to blood loss, and it is classified into four grades.(Mohanty et al., 2005).) despite the fact that it is a life-threatening condition, immediate recognition of haemorrhagic shock instigated by appropriate and timely intervention can save lives. Management of haemorrhagic shock in low income states is a very big challenge bearing in mind it is a quite expensive procedure and requires adequate blood transfusion services which recently are unavailable. stands to be one of life menacing conditions which day to day preys the lives of many patients with trauma conditions globally, especially in the low and middle income countries () it is also the primary  preventable death amid death among patients suffering from trauma. Globally trauma is the number one cause of demise in kids over 5 years, young adults and teenagers, accounting for about 10% of mortality at large. In tropical sub Saharan countries, most deaths occurs in towns largely because of trauma (Holcomb et al., 2015).
Road accidents are the leading cause of hemorrhagic shock, and it is estimated over 1,2 million people die globally annually from this epidemic.  With the increase in the number of motor cars in middle and low-income countries, mortality rate is projected to increase by 80% from the year 200o to 2020 (Giannoudis, & Pape, 2017). An important number of deaths resulting from this type of trauma are mainly led by uncontrolled hemorrhage causing an upsurge of haemorrhagic shock to increase and advance patients endurance. Lastly some trauma leading to this circumstances include gunshot injury, mob justice, assault, and many others.
Since the year 2000 injuries had a negative link with mortality, while the age of the patient, pre-hospital provide care and mechanism of injury, didn’t affect mortality but over the years there has been a significant improvement from the following. It is therefore crucial to strategies to reduce mortality and put in place, in-hospital and pre-hospital, relating control, injury, patient management, and prevention. Vital signs and serum lactate levels to check and monitor revival in trauma patients. For critical patients, it is essential to carefully, monitor, and follow them for more extended periods of time.
Part B:
Critically evaluate how the management of hemorrhagic shock due to torso trauma has evolved since 2000 and the key drivers for these changes
Most deaths of traumatic patients have majorly been caused by uncontrolled post-traumatic bleeding ((Holcomb et al., 2015). During hospital admissions, about one-third of patients suffering from post-traumatic bleeding are presented with a coagulopathy. This subclass of patients has increased the incidences of death and multiple organ failures significantly in comparison with patients that have similar patterns of injury without the coagulopathy. Managing patients with massive bleeding appropriately, which has been defined here as the loss of a single blood volume within 24 hours or losing 0.5 blood volume in three hours. It involves identifying potential blood loss early and devising ways to prevent loss of blood, achieve the stability of hemodynamic and tissue restoration perfusion. Examples of confounding factors include pre-medication, co-morbidities, and physical parameters that take part in the coagulopathic state. Recently, the early acute coagulopathy linked to traumatic injury has been known as a primary multifactorial condition that can be caused by a combination of shock, activation of fibrinolytic and anticoagulant pathways, and trauma of tissues related to thrombin generation. The conditions are affected by therapeutic and environmental factors which contribute to hypothermia, acidaemia, hypoperfusion, hemostasis, and dilution factor conditions. (Hunt et al., 2015).  The concept of early post-traumatic coagulopathy may evolve therefore it is necessary to review past data. As years go by, researchers are likely to come up with data that doubtlessly create a clear understanding of the advantages and risks of different therapeutic methods applied to this group of patients.
These commendations were graded and formulated according to the Grading of Recommendations Assessment. Complete database search was conducted using PubMed and Cochrane library online databases. The literature used was also cited. The primary objective of this paper was to classify the potential randomized controlled trials (RCTs) and the non-RCTs that exist in systematic guidelines and reviews. Without such evidence, the case reports, observational studies and case reports were considered.
The medical subject heading (MeSH) and Boolean operators’ thesaurus keywords were used as the standard language to unite the differences in terminologies in one concept. Additionally, the appropriate headings and subheading of MeSH for each question were selected and modified basing it on the research results. The searches were limited the human studies, and English language abstracts and gender and age was not limited. The time interval of the information used was from three years ago up to date. However, no time was limited to the new searches. The primary publications were evaluated for all relevant abstracts. The principal papers were classified based on the level of evidence provided by the Oxford Center of Evidence-based medicine.
Members of the task force for multidisciplinary, advanced post-trauma bleeding, anesthesia, intensive care medicine, emergency medicine and hematology performed the selection of scientific inquiries and gave grading, screening as well as guidelines of the literature to be used. They also performed a formulation of the explicit recommendations. The central group formed in 2004 provided educational materials on how to care for post-traumatic bleeding in patients. An update was done in 2006, and further reviews of related have been done. The task force involved in the research comprised of hematology experts, representatives from relevant European societies of professionals (European Society of Intensive Care Medicine, the European Society of Anaesthesiology, the European shock Society) and the guideline development experts.
The members of the task force participated in workshops to develop guidelines that led to the 2007 instructions. During the workshops, members were able to work on appraising critiques of medical literature. The updated guidelines had several remote meetings and face to face meetings accompanied by numerous Delphi rounds. In 2009, members developing guidelines participated in a web conference to describe the scientific questions which will be incorporated into the guidelines.  Subcommittee groups were formed to perform grading, selection, and screening of literature as well as the formulation of the recommendations. This subcommittee consisted of three members connected through telephones. Finally, in June 2009, members met to reach a consensus on the proposals presented by each subcommittee. A complete manuscript with updated documents was approved and endorsed in January 2010 (Rossaint et al., 2010).
The principal changes in this updated manuscript include the new recommendations on monitoring, the appropriate use of local measures of hemostatic and coagulation support, calcium, tourniquets, and desmopressin in the post-traumatic bleeding in patients. Other recommendations have been re-examined based on the literature published after the last updated guidelines. The clinical practice has also received changes in the overall accessibility of applicable agents and technologies after the last updated guidelines. This guideline, therefore, provides a multidisciplinary approach based on previous evidence to help manage and care for patients with post-traumatic bleedings (Hunt et al., 2015).
Part C:
Critically discuss the evidence-based management of the hemodynamically unstable patient with a pelvic fracture and a splenic injury
To bring out the concept of discussion in this part well, we look at an atypical case of a wobbly pelvic fracture in a pregnancy interlude; the patient had suffered a splenic rupture which had instigated enormous hemorrhage in the abdomen. Unluckily, she sustained a fetal death. Looking into latent causes of fetal death, undeviating shock to the uterus, fetus or placenta wasn’t part of the fetal demise, in disparity with maternal hemorrhage. Careful peri-,pre- and post-operative assessment of the fetus and the mother by multidisciplinary team.
Keywords: Fetal death; Splenic rupture; Pregnancy; Pelvis fracture
Case of patients with a hemodynamically wobbly pelvic fissure in pregnancy and belated rupture following trauma are very rare, and for that reason, they contribute to high mortality rate. Bearing in mind the fact that these cases are absolutely very scarce, factors given priority during their procedures involve the essential of surgical intervention, timing, good utilization of internal fixation and administering medication after and before surgery. Therapeutic strategy is crucial in such situations to achieve an excellent result for the patient with reasonable risk. We bring to board a strange case of a pelvic fracture in an expectant patient in the second trimester, anguishing from spleeny rupture and fetal demise which had developed due to enormous delayed hemorrhage in the abdomen. The breach was treated surgically by internal fixation and open fixation from splenic split while the procedure is progressing is predominantly well thought-out. A re-examine of previously reported cases is involved with the discussion of this challenging dilemma(Peng et al., 2012).
Acetabular and pelvic fractures in pregnancy are regularly reported in the literature, which is connected to a soaring maternal which is nine percent and a higher fetal thirty five percent mortality rate, in spite of the type of the trimester or pelvic fracture. Many road carnages account for a considerable portion of blunt trauma during pregnancy, and the leading cause of death in females amid the age of 8-28 years. Likely cause of fetal demise is direct trauma to the fetus, uterus or placenta and maternal blood loss with ensuing fetal hypoxia. Looking at this case, the severance of the pubic symphysis might have the happened from decreasing forces of the fetal head onto the progressive forces to the pelvis.
This fetal death was caused mainly due to a placental abruption attained in the course of the accident. The spleen of all is the most injured organ in blunt abdominal trauma. Conversely traumatic rupture of a healthy spleen is exceptional. This reason may be because it is healthy confined position in the left upper quadrant of the tummy. Though delayed fracture of sleep in pregnancy has not been described. in this incident, for instance, the patient depicted symptoms and signs of severe intraperitoneal bleeding 20 hours after the event. The first abdominal ultrasound is examining scan pictured crack with 6.5cm x 1.0cm gratis fluid, whereas the second scan showed a hemoperitoneum with merely 0.8L of blood. Surprisingly she was unwavering stable without hypotension.
It gives indications that the transmitted force to the spleen is enough to tear the splenic parenchyma but hurt the capsule. At the occasion intrasplenic bleeding continues, a subcapsular hematoma is generated with a progressive boost in the intrasplenic force, and rupture of the capsule happens with ensuing intraperitoneal hemorrhage. This is the primarily accepted theory perisplenic hematoma and capsular tear are made and tamponaded by adjacent organs, in particular, the pregnant uterus, which reduces the intraperitoneal hemorrhage or impediment its rupture. On top of that, preliminary bleeding from splenic laceration would be blocked by a perisplenic hematoma but commence later on when hematoma is dislodged. It is very crucial to repeat radiology imaging throughout the latent phase while establishing the diagnosis. Nevertheless, a typical Ct or ultrasound does not leave out a belated splenic rupture.
Surgeons need to be keen mainly when monitoring occult splenic damage in the case where the intraperitoneal fluid recognized with no a lucid source, in particular, more than trace in women of below menopause. Additionally, it may be noted that some hemorrhage seen along fascial planes neighboring the spleen that are signals of potential injury to the spleen, they include lateral conal fascia. Splenectomy is still the basis of surgical treatment in many of the instances.  Blood transfusion is perpetually needed to give artificial respiration to the patient. Given that the engorged uterus possibly will alter the anatomical relations of the abdominal organs, laparotomy instigated by cesarean segment is frequently required to indicate the position of bleeding.
Vertical, paramedian or midian instead of the transverse slit on lower abdomen permit easier extension and entrée. On the occasion the fetus is dead, the therapeutic scheme should put into consideration the possibilities of maternal injuries including traumatic rupture of spleen and a dead fetus. Fetal demise can directly lead to disseminating intravascular coagulation (DIC) or fetal death syndrome. The responsibility of the tissue factor in the progress of tender DIC vestiges to be obscure and won’t be addressed by this study, the reason behind being that the patient didn’t have DIC and the present medical  custom of induction of labor subsequently the diagnosis of a dead fetus looks like it is preventing this maternal impediment. (conversely, patients with a fetal death have improved platelet indices and activation of the hemostatic system. The cure of pelvic and dead fetus has an extremely high possibility of venous thrombosis. This, together with the known hypercoagulable state of pregnancy owing to improved circulating clotting aspect, depicts the normal use of antithrombotic. Concerning anticoagulation, fondaparinux and low-molecular-weight are the fastest. Splenectomy and the caesarean possibly will free the maternal life from hemorrhagic situation. When the patient is stable, a treatment procedure of the pelvic fracture becomes possible. The combination of pubic symphysis and pelvic fracture separation may instigate a number of complications that includes difficulty in ambulation, pain and bladder dysfunction. For patients who are pregnant, a number of stabilization methods for wobbly fractures of the pelvic ring show a good clinical result. However in the case discussed,  the procedure is linked with caesarean section and splenectomy. The goal of the treatment is to attain discretionary optimal clinical results and concurrently ease the maternal risk to satisfactory level.
Knowing these attestations, therefore it is recommended one can undertake the operative stabilization of the pelvic fracture. Looking at the facts presented in the paper, this is among the preliminary paper presenting insight in both splenic rupture and unstable pelvic fracture and most importantly to note also features facts on a dead fetus. Even though rare, the possibility of splenic rupture ought to be well thought-out during the diagnosis in pregnant patients with blunt abdominal trauma, even when she is hemodynamically stable. Early splenectomy and diagnosis reduce the mortality and maternal mobility. (Costantini et al., 2016).