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John B. Holcomb, MD, FACS Professor and Vice Chair of Surgery University of Texas Health Science Center, Houston, TX 1 Damage Control Resuscitation

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Nothing to Disclose 2

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Texas Trauma Institute Houston, TX 3

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Memorial Hermann-TMC and UT Health Trauma Volume - 2012 Update slide 4

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In 2010, there were 5.1 million deaths from injuries 10% of all deaths and the total number of deaths from injuries was greater than the number from infection with HIV, tuberculosis, and malaria combined (3.8 million). Overall, the number of deaths from injuries increased by 24% between 1990 and 2010. 5 May 2, 2013

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Years of Potential Life Lost (YPLL) Before Age 65 Cause of Death YPLL Percent All Causes 948,426 100.0% Unintentional Injury 199,903 21.1% Suicide 52,265 5.5% Homicide 48,190 5.1% Malignant Neoplasms 137,221 14.5% Heart Disease 107,009 11.3% Perinatal Period 75,496 8.0% Congenital Anomalies 43,615 4.6% Cerebrovascular 21,817 2.3% HIV 21,508 2.3% Liver Disease 21,352 2.3% All Others 220,050 23.2% The National Center for Injury Prevention and Control. Web-based Injury Statistics Query and Reporting System. US Department of Health and Human Services, CDC; 2008. Available at: http://www.cdc.gov/ncipc/wisqars/. Accessed May 22, 2009.http://www.cdc.gov/ncipc/wisqars/ 31.7% 6

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UTHSC-Houston 1999-2008 Trauma admissions = 36,028 and 2394 deaths = 6.6% Early deaths ( 24 hrs) = 1398 or 58% 7 Deaths from day 31-171 = 68/2394 = 3% 30 days = 97%

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8 J Trauma 2012 2001 - 2011, 4,596 battlefield fatalities were reviewed 87% (n = 4012) of all injury mortality occurred pre-MTF 24% (n = 976) were deemed potentially survivable (PS) 91% (n = 888) died from hemorrhage

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Bottom Line Up Front Crystalloid resuscitation increase blood loss, transfusion requirements and death Balanced blood product resuscitation decreases blood loss, transfusion requirements and improves survival Must have thawed/liquid plasma in the ED to really do this well Time is critical 9

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How to Resuscitate? Its not just raise the BP Not just the hole in the blood vessel that needs rapid suture Why do we give RBCs first? Red stuff Reverse the systemic and iatrogenic endothelial injury Reverse permeability Prevent edema Repair the endothelium Dampen the systemic inflammatory response Prevent and Reverse coagulopathy Time is important 10

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11 Rapid progress in trauma care occurs during a war. Damage control resuscitation addresses diagnosis and treatment of the entire lethal triad immediately upon admission. J Trauma, 2007.

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DCR components Stop bleeding Hypotensive resuscitation Minimize crystalloid Use thawed plasma to resuscitate patients Increased platelet use Reverse hypothermia and acidosis Hemostatic adjuncts 12

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13 J Trauma 2012

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Typical 24 hour Resuscitation THEN 20 liters of LR 15 RBCs 5 FFP 0 platelets 14 Associated with decreased edema, MOF and improved survival NOW 3-5 liters of LR 7 RBCs 6 FFP 1 platelets

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17 yr, GSW Liver, 60/30, BD-17 11 RBC 10 FFP 2 platelet 3 liters crystalloid 3 ops Home in 8 days 2010

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Rt pulmonary lower lobe wedge, Rt hepatic lobectomy, Rt nephrectomy 14 RBC 14 FFP 2 platelets 2 cryo 2 liters of crystalloid 2014

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Post Operative Damage Control Laparotomy and Thoracotomy

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5 days post op Home day 10

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Component Therapy Component Therapy: 1U PRBC + 1U PLT + 1U FFP + 1 U cryo COLD 680 COLD mL Hct 29% Plt 80K Coag factors 65% of initial concentration WWB: 500 mL Warm Hct: 38-50% Plt: 150-400K Coag: 100% 1000 mg Fibrinogen Armand & Hess, Transfusion Med. Rev., 2003

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Which one to use, start, how much, stop ?? 21

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Plasma and Platelets for everyone? Dzik WH. Predicting hemorrhage using preoperative coagulation screening assays. Curr Hematol Rep. 2004. Gajic O, Dzik WH, Toy P. Fresh frozen plasma and platelet transfusion for nonbleeding patients in the intensive care unit: benefit or harm? Crit Care Med. 2006. Abdel-Wahab OI, Healy B, Dzik WH. Effect of fresh-frozen plasma transfusion on PT and bleeding in patients with mild coagulation abnormalities. Transfusion. 2006. 22

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23 2003-2004, n = 252 P < 0.05 162 53 16231 J Trauma, 2007

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Multicenter (16) Retrospective Massive Transfusion Study 12 months data collection 30,000 admissions and 11,650 transfused 466 MTs 24 Ann Surg 2008

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25 30 day Kaplan-Meier

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26 JACS 2010 12 hrs24 hrs

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Ann of Surg, 2011 2004-2008 vs 2008-2010

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DCR in DCL: DCR patients received less, (p