RECENTLY EXPANDED 4 YEAR MEDICAL SCHOOL

COLLABORATION WITH NOTRE DAME’S KECK TRANSGENE REASEACH CENTER

MEMORIAL HOSPITAL LEVEL II TRAUMA CENTER

WE ARE……………………

Normal TEG

Army’s Aggressive Surgeon Is Too Aggressive for Some

Erich Schlegel for The New York Times

CRITICAL CARE Col. John Holcomb, a top trauma surgeon in the Army.

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By ALEX BERENSON Published: November 6, 2007

Correction Appended

SAN ANTONIO — Since the war in Iraq began, Col. John Holcomb has been working to change the way the military takes care of its wounded.

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J Trauma, Oct 2008

16Cosgriff N, et al. Predicting life-threatening coagulopathy in the massively transfused patient: Hypothermia and acidosis revisited. J Trauma. 1997.

“Koolaid”

Acute Traumatic Coagulopathy

No FFP in trauma resuscitation Old time resuscitation give FFP when

you realize that what is running down your shoes is like “Kool Aid”

1/1/1 Damage Control Resuscitation Thromboelastographic Point of Care

“Goal Directed “Blood Component Therapy

V.S. BP 115/80, P 124, RR 28 I survey Airway patent, labored breathing,

BS absent on right thready pulse pulse: R hemothorax: respiratory arrest

Intubated, chest tube immediate drain 2000 cc blood right chest

FAST demonstrates pericardial effusion and evidence of right ventricular collapse.

Cardiac surgeon: Pericardial window done in ED Atrial appendage clamped

BCT in ED and in OR based on TEG guided Goal Directed therapy

CV surgeon and trauma surgeon quickly extend pericardial window

Anesthesiologist and the perfusionist give blood components based on the TEGs. Total 60 PRBC units BCT Ratios: 1PRBC/.5FFP…..1PRBC/1Platelets

Patient needs volume and fibrinogen so given more FFP instead of cryoprecipitate.

Recovers

FAST Pericardial Window OR BCT lead by anesthesiologist and

perfusionist Fibrinogen given by FFP instead of

cryoprecipitate Decision to close the abdomen Need to take the patient back to surgery Serial TEGs with platelet mapping Platelet count of 42,000 yet good platelet

function TEG/PM guided goal directed BCT

, U Thoracic and Cardiovascular Surgery. 2009 Volume 13 Number 1

Blue Phantom Ultrasound Training Module

1) 4 units O- PRBC 2) 2 units FFB 3) 1 SD Apheresis Platelet started in

ER on way to OR 4) Surgical repair of injured colon,

bladder, mesentary with colostomy, intraoperative interventional radiology coiling of bleeding pelvic vessels and external fixation of pelvic fracture.

1) Initial Fibrinolysis treated with BCT which included cryoprecipitate as well as PRBC, FFP, Platelets with similar ratios as previous cases, i.e.

1 PRBC/.5FFP 1 PRBC/1 Platelet Amicar also given dose 5grams Patient survives

Damage Control Laparotomy , Colostomy, OR/IR coiling of internal iliac artey branch

Scrotum

External Fixation after Laparotomy and Colostomy

TOP

Bottom

Scrotum

Good Clot

Hoffman M, Monroe DM, Roberts HR. Human monocytes support factor X activation by factor VIIa independent of tissue factor: implications for the therapeutic mechanism of high dose factor VIIa in hemophilia. 1994 BLOOD83:38-42

Monroe DM, Roberts HR, Hoffman M. Platelet procoagulant complex assembly in a tissuefactor-initiated system. Br J Haematol 1994;88:364–71.

“Using this model we have evolved a conceptual model of coagulation that better explains the physiology of some clotting and bleeding disorders than does the previous coagulation cascade model.”

From Dr. Hoffman’s Website for Graduate Studies at Duke University

Hoffman M, Monroe DM, Oliver JA, et al. Factors IXa and Xa play distinct roles in tissue factor-dependent initiation of coagulation. Blood 1995;86:1794–801.

Monroe DM, Hoffman M, Roberts HR. Transmission of a procoagulant signal from tissue factor-bearing cell to platelets. Blood Coagul Fibrinolysis 1996;7:459–64.

Hoffman M, Monroe DM 3rd. A cell-based model of hemostasis. Thromb Haemost2001;85:958–65.

We propose that coagulation occurs not as a "cascade", but in three overlapping stages: 1) initiation, which occurs on a tissue factor bearing cell; 2) amplification, in which platelets and cofactors are activated to set the stage for large scale thrombin generation; and 3) propagation, in which large amounts of thrombin are generated on the platelet surface. This cell based model explains some aspects of hemostasis that a protein-centric model does not.

Furthermore, whereas civilian blunt trauma victims may have a "golden hour," casualties with penetrating battlefield trauma often have only a "platinum 5 minutes." Because of the challenges of treating hemorrhage during combat, it is important for military medical personnel to understand their options for treating hemorrhage quickly and efficiently.

Rao SV, Jollis JG, Harrington RA, Granger CB, Newby LK, Armstrong PW, Moliterno DJ, Lindblad L, Pieper K, Topol EJ, Stamler JS, Califf RM.

Relationship of blood transfusion and clinical outcomes in patients with acute coronary syndromes.

JAMA. 2004 Oct 6;292(13):1555-62.

Currently, 10–15% of patients presenting with ACS have to undergo aorto-coronary artery bypass grafting (CABG) and 5% to 25% of patients have to undergo non-cardiac surgery during the first five years after PCI(7, 8). While preoperative discontinuation of antiplatelet therapy is associated with ∼20% incidence of ischaemic events, continuation puts patients at ∼35% incidence of bleeding (9–11). Likewise, bleeding and transfusion of red blood cells have been associate with increased risk of infection, myocardial infarction and mortality

(13–15). #13 is Dr. Rao’s European Heart Journal

Based on the results of the Clopidogrel in Unstable Angina to Prevent Recurrent Events Trial (CURE) and the Trial to assess Improvement in Therapeutic Outcomes by optimizing platelet Inhibition with prasugrel Thrombolysis In Myocardial Infarction 38 (TRITONTIMI 38) current guidelines for cardiac surgery recommend withholding clopidogrel for at least five days and prasugrel at least seven days before scheduled CABG in order to limit blood loss and transfusion (class I recommendation, level of evidence C) (17–19).

“In TRITONTIMI 38, prasugrel was associated with a significant four-fold increased relative risk (absolute difference: 10.2%) of CABG related bleeding as compared to clopidogrel (19). Furthermore, the observation that a short time interval between clopidogrel withdrawal and surgery precipitates the risk of bleeding, suggests the association between insufficient platelet function recovery and bleeding.”

The clinical relevance of platelet function has so far been investigated in cardiology and cardiovascular surgery (7); however, reports on platelet function following trauma are limited (8). Due to logistical problems, routinemeasurement of platelet function can be problematic in the challenging scenario of acute trauma care. Born aggregometry, the current gold standard for the assessment of platelet function, is a labour-intensive technique which is not available in most trauma centres. In contrast, multiple electrode impedance aggregometry (MEA; MultiplateR, Verum Diagnostica GmbH, Munich, Germany)is a newly developed, semi-automated platelet functionanalyser that measures platelet function in whole blood and is readily applicable as a point-of-care monitoring device (9).

Holcomb JB, Wade CE, Michalek JE, et al. Increased plasma and platelet to red cell ratios improves outcome in 466 massively transfused civilian trauma patients. Ann Surg 2008;248:447-458.

The Impact of Platelet Transfusion in Massively Transfused Trauma Patients

Kenji Inaba, MD, FACS, Thomas Lustenberger, MD, Peter Rhee, MD, FACS, John B Holcomb, MD, FACS,Lorne H Blackbourne, MD, FACS, Ira Shulman, MD, Janice Nelson, MD, Peep Talving, MD, FACS, Demetrios Demetriades, MD, FACS (J Am Coll Surg 2010;211: 573–579. 2010)

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79

Total 8 U PRBC, 2 U FFP, 2 SD plts TEG-PM driven not by blind 1:1:1

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History of aspirin use was not given and patient is tachycardic

CT scan 16 cm pelvic hematoma with only a small superior pubic ramus fracture

Internal iliac branch “vessel” tear Coiled Resuscitated with BCT no crystalloid Remembered ASA use. Note quick response to ADP Note still delayed response to AA

37yo female Grade IV Liver Injury Abnormal PM with normal TEG hence

greater ratio of platelets Quick Response to Platelets and

greater ratio of platelets to PRBC for this very significant liver laceration

Pre TEGPre TEG ( n = 68 )( n = 68 ) Post TEGPost TEG

-13-13 ED : BDED : BD -15-15

1.61.6 ED : INRED : INR 1.81.8

18.018.0 RBC / 6 hrRBC / 6 hr 17.217.2

6.86.8 FFP / 6 hrFFP / 6 hr 6.56.5

65%65% MortalityMortality 29%29%

21%21% CoagulopathyCoagulopathy 3%3%

AAST 2009AAST 2009

For every one unit drop in G value (clot strength) by one hour, risk of PF increases by 30% and death by >10%

% Change in Prothrombin Time

% Change in Clot Firmness

Brohi et alJ Trauma 2011

Coagulation Status … after every 4 U RBC( n = 50 Mortality = 36 % )

MTP Protocol useful MTP underestimates need for BCT Crystalloid infusion for patients in shock is

harmful Historical response to avoidance of

Crystalloid resuscitation harm has bee DCR 1/1/1

How much FFP to give? Resort to the TEG POC “Goal Directed” BCT Fable of the Three Bears

JUST RIGHT

The code is more what you'd call “guidelines” than actual rules

“Welcome aboard the Black Pearl, Dr. White”

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