Management bleeding and coagulopathy fixed.pptx

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    Management of bleeding and

    coagulopathy following major trauma: anupdate European guideline

    Donat R Spahn, Bertil Bouillon, Vladimir Cerny, imothy ! Coat", !ac#ue" Duranteau,Enri#ue $ern%nde&'Mond(jar, Daniela $ilipe"cu, Be)erley ! *unt, Rad+o omadina, -iu"eppe .ardi,Edmund .eugebauer, /)e" 0&ier, 1oui" Ridde&, 2rthur Schult&, !ean'1oui" Vincent and Rolf Ro""aint

    Journal Reading

    Critical Care 3456, 57: R78

    0leh:2lfred * 1 oruan

    9embimbing :dr 0+y Su"ianto, Sp 2n ;C

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    ;ntroduction•

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    Material and Method• Recommendation" were formulated ad graded

    with -R2DE "y"tem by committee of e=pert"• Search from online databa"e MED1;.E>9ubMed• 9rimary intention RC and non'RC , "y"tematic

    re)iew and guideline"

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    Re"ult5? ;nitial re"u"citation and pre)ention of further

    bleedinga Minimal elap"ed time

    Recommendation 1 @e recommend that the time elap"edbetween injury and operation be minimi"ed for patient" inneed of urgent "urgical bleeding A-rade ;2?

    More than 4 of all trauma patient" with a fataloutcome die within 3 h of injury

    b orni#uet u"eRecommendation 2 @e recommend adjunct torni#uet to"top life'threatening bleeding from open e=tremity injurie"in the pre'"urgical "etting A-rade ;B?

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    c VentilationRecommendation 3 @e recommend initialnormo)entilation of trauma patient" if there are no"ign" of imminent cerebral herniation A-rade 5C?

    *yper)entilated trauma patient" appear to ha)eincrea"e mortality when compared with non'traumaRoutine hyper)entilation in head injured patient" ad)er"e outcome"

    .o B; hyper)entilation "till debateEarly u"e of protecti)e )entilation with low tidal)olune and moderate 9EE9 i" recommended,particularly in bleeding trauma patient" at ri"+ ofacute lung injury

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    3? Diagno"i" and monitoring of bleedinga ;nitial a""e""ment

    Recommendation 4 @e recommend that the phy"icianu"ing a combination of patient phy"iology, anatomical

    injury pattenrn, mechani"m of injury, and the patient "re"pon"e to initial re"u"citation A-rade 5C?

    Vi"ual e"timation of blood lo""Mechani"m injury ri"+ for "igniFcant traumatichemorrhage, injury "e)erity

    2S* "core SB9, *b, intra'abdominal Guid,comple= long bone and>or pel)ic fracture, *R, BE,and gender

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    b ;mmediate inter)entionRecommendation 5 @e recommend that patien"pre"enting with haemorrhagic "hoc+ and an identiFed"ource of bleeding undergo and immedite bleeding

    control procedure unle"" initial re"u"citation mea"ure"are "ucce""ful A-rade 5B?Source of bleeding may be immediately ob)iou",and penetrating injurie" are more li+ely to re#uire"urgical bleeding control

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    c $urther in)e"tigationRecommendation 6 @e recommend that patient"pre"enting with haemorrhagic "hoc+ and anunidentiFed "ource of bleeding undergo immedate

    further in)e"tigation A-rade 5B?*aemorrhagic "hoc+ a""e""ment of che"t,abdominal ca)ity and pel)ic ringRecommended diagno"tic modalitie" H'ray ofche"t and pel)i", ultra"onography or D91

    2)ailable C '"can may replace con)entionalradiographic

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    d ;magingRecommendation 7 @e recommend early imagingAultra"onograpy or C ? for the detection of free Guid inpatient" with "u"pected tor"o trauma A-rade 5B?

    e ;nter)entionRecommendation 8 @e recommend that patient" with"ignFcant free intra'abdominal Guid andhaemodynamic in"tability undergo urgent

    in)e"tigation A-rade 52?

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    f $urther a""e""mentRecommendation 9 @e recommend further a""e""mentu"ing C for haemodynamically "table patient" A-rade 5B?

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    g *aematocritRecommendation 10 @e do not recommend the u"e of"ingle *ct mea"urement" a" an i"olated laboratorymar+er for bleeding A-rade 5B?

    9atient" bleed whole blood and compen"atorymechani"m" that mo)e Guid" from inter"titial"pace re#uire time and are not reGected in initial*C mea"urement

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    h Serum lactate and ba"e deFcitRecommendation 11 @e recommend either "erum lactate orba"e deFcit mea"urement" a" "en"iti)e te"t" to e"timate andmonitor the e=tent of bleeding and "hoc+ A-rade 5B?

    1actate le)el" returned to the normal range AI 3 mmol>l?within 3 h "ur)i)ed, "ur)i)al decrea"e to 77,J ifnormali"ation occurred within J h and to 56,8 if morethan J h1actate can be increa"e with alcohol ba"e deFcit betterpredictor

    Ba"e deFcit predictor of mortality with traumatic'hemorrhagic "hoc+ di)ide into three le)el: mild A'6 to' ?, moderate A'8 to 'K? and "e)ere A L'54?BE "igniFcant correlation between admi""ion ba"edeFcit, tran"fu"ion re#uirement" within the Fr"t 3 h andthe ri"+ of po"t'traumatic organ failure or death

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    i Coagulation monitoringRecommendation 12 @e recommend that routine practice todetect po"t'traumatic coagulopathy include the early, repeatedand combined mea"urement of prothombin time A9 ?, acti)atedpartial thrombopla"tin time A29 ?, Fbrinogen and platelet"

    A-rade [email protected] recommend that )i"coela"tic method" al"o be performed toa""i"t in characteri"ing the coagulopathy and in guidinghaemo"tatic therapy A-rade 5C?

    Con)entional coagulation "creen A;.R and 29 ? monitoronly the initiation pha"e of blood coagulation, and repre"ent

    only the Fr"t of thrombin production po""ible appearnormal, while the o)erall "tate of blood coagulation i"abnormal

    ool" for chec+ coagulopathy tromboela"tometry, portablecoagulometer", tromboela"tography delay in detection oftraumatic coagulopathy can inGuence outcome

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    6? i""ue o=ygenation, Guid, and hypothermiaa i""ue o=ygenation

    Recommendation 13 @e recommend a target "y"tolic blood

    pre""ure of J4 to K4 mm*g until major bleeding ha" been "toppedin the initial pha"e following trauma without brain injury A-rade [email protected] recommend that a mean arterial pre""ure J4 mm*g bemaintained in patient" with comined haemorrhagic "hoc+ and"e)ere B; A-CS IJ? A-rade 5C?

    2ggre""i)e Guid admini"tration increa"e hydro"tatic pre""ureon the wound, cau"e di"lodgement of blood clot", a dilution ofcoagulation factor" and unde"irable cooling of patient2ggre""i)e Guid admini"tration great predictor of "econdary2CSCoagulopathy wa" ob"er)ed N 4 of patient" with N3444 ml,

    N 4 with N6444 ml, N74 with N 444 ml1ow )olume approach in hypoten"i)e patient" i"contraindicated in B; and "pinal injurie", becau"e an ade#uateperfu"ion pre""ure i" crucial to en"ure ti""ue o=ygenation of theinjured central ner)ou" "y"tem

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    b $luid therapyRecommendation 14 @e recommend that Guid therapybe initiated in the hypoten"i)e bleeding traumapatient A-rade 52?

    @e recommend that cry"talloid" be applied initiallyto treat the hypoten"i)e bleeding trauma patientA-rade 5B?

    @e recommend that hypotonic "olution", "uch a"Ringer " lactate, be a)oided in patient" with "e)ere

    head trauma A-rade 5C?;f colloid" are admini"tered, we recommend u"ewithin the pre"cribed limit" for each "olution A-rade5B?

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    @e "ugge"t that hypertonic "oluton" during initial treatmentbe u"ed, but demon"trate no ad)antage compared tocry"talloid" or colloid" in blunt trauma and B; A-rade [email protected] "ugge"t the u"e of hypertonic "olution" inhemodynaically un"table patient" with penetrating tor"o

    trauma A-rade 3C?Chochrane meta analy"i" on the type of Guid could notdemon"trate that colloid reduce the ri"+ of deathcompared to re"u"citation with cry"talloid;f high ratio $$9: RBC cannot be admini"tered to traumapatient", re"u"citation with at lea"t 51 cry"talloid per unitRBC "eem" to be a""ociated with reduce o)erall mortalityE)idence "ugge"t that hypertonic "aline "olution" are"afe, but will neither impro)e "ur)i)al nor impro)eneurologiccal outcome after B;

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    c Va"opre""or" and inotropic agent"Recommendation 15 @e "ugge"t admini"tration of)a"opre""or" to maintain target arterial pre""ure inthe ab"ence of a re"pon"e to Guid therapy A-rade 3C?

    @e "ugge"t infu"ion of an inotropic agent in thepre"ence of myocardial dy"function A-rade 3C?Re"tore M29 and "y"temic blood Gow in "hoc+re"u"citation u"ing )a"opre""or .E A"epticand haemorrhagic "hoc+?

    9oor re"pon"e to Guid e=pan"ion and .E con"ider cardiac dy"function u"ing inotropicagent" Adobutamin or epinephrine?

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    d emperature managementRecommendation 16 @e recommend early application of mea"ure" toreduce heat lo"" and warm the hypothermic patient in order to achie)eand maintain normothermia A-rade [email protected] "ugge"t that hypothermia at 66 to 6 OC for Jh be applied inpatient" with B; once bleeding from other "ource" ha" been controlledA-rade 3C?

    EPect" of hypothermia altered platelet function, impairedcoagulation factor function, en&yme inhibition and Fbrinoly"i" pre)ent by remo)e wet clothing, co)ering patient to a)oidadditional heat lo"", increa"ing the ambient temperature, forced airwarming, warm Guid therapy and e=tracorporeal re'warming de)ice"

    9rolonged hypothermia may be con"idered in patient" with i"olatedhead trauma "hould ta+e 6 h following injury Fr"t, colling headand nec+, maintain for N Jh, rewarming 3 h, C99 maintaned atN 4 mm*g ASB9 74 mm*g? benFt for -CS between and 7 lower mortality and po"iti)e neurological outcome

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    e Erythrocyte"Recommendation 17 @e recommend a targethaemoglobin A*b? of 7 to K g>d1 A-rade 5C?

    Decrea"e *b hypo=ia phy"iologic re"pon"e"

    to acute normo)olaemic anaemia, including macroand micro circulatory change compe"ate for thedecrea"e

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    ? Rapid control of bleedinga Early abdominal bleeding control

    Recommendation 18 @e recommend that earlybleeding control of the abdomen be achie)ed u"ing

    pac+ing, direct "urgical bleeding control and the u"e oflocal haemo"tatic procedure" ;n the e="anguinatingpatient, aortic cro""'clamping may be employed a" anadjunct A-rade 5C?

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    b 9el)ic ring clo"ure and "tabili"ationRecommendation 19 @e recommend that patient" with pel)ic ringdi"ruption in haemorrhagic "hoc+ undergo immediate pel)ic ringcclo"ure and "tabili"ation A-rade 5B?

    c 9ac+ing, emboli"ation, and "urgeryRecommendation 20 @e recommend that patient" with ongoinghaemodynamic in"tability de"pite ade#uate pel)ic ring"tabili"ation recei)e early preperitoneal pac+ing, angiographicemboli"ation and>or "urgical bleeding control A-rade 5B?

    Mar+er pel)ic haemorrhage 29 and )erticcal "hear

    deformation, C Qblu"h , bladder compre""ion pre""ure, pel)ichaematoma )ol N 44 cc e)ident by C , and ongoinghaemodynamic in"tability de"pite ade#uate fracture"tabili"ation

    herapy for crucial time pel)ic clo"ure bed "heet, pel)icbinder, pel)ic C'clamp

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    d Damage control "urgeryRecommendation 21 @e recommend that damagecontrol "urgery be employed in the "e)erely injuredpatient pre"enting with deep hameorrhagic "hoc+, "ign"of ongoing bleeding and coagulopathy A-rade 5B?0ther factor" that "hould trigger a damage controlapproach are "e)ere coaguloaty, hypothermia, acido"i",an inacce""ible major anatomic injury, a need for time'con"uming procedure" or concomitant major injuryout"ide the abdomen A-rade [email protected] recommend primary deFniti)e "urgicalmanagement in the haemodynamically "table patientand in the ab"ence of any of the factor" abo)e A-rade5C?

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    e 1ocal haemo"tatic mea"ure"Recommendation 22 @e recommend the u"e of topicalhaemo"tatic agent" in combination with other "urgicalmea"ure" or with pac+ing for )enou" or moderatearterial bleeding a""ociated with parenchymal injurie"A-rade 5B?

    2gent" collagen, gelatine or cellulo"e'ba"edproduct", Fbrin and "ynthetic glue" or adhe"i)e"that can be u"e for both e=ternal and internalbleeding while poly"acharide'ba"ed and inorganichaemo"tatic" are "till mainly u"ed and appro)ed fore=ternal bleeding

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    ? Management of bleeding and coagulationa Coagulation "upport

    Recommendation 23 @e recommend that monitoringand mea"ure" to "upport coagulation be initiated a"

    early a" po""ible A-rade 5C?Major trauma bleeding and coagulopathyEarly coagulopathy found in patient" withhypoperfu"ion Aba"e deFcit N8mE>1?

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    b 2ntiFbrinolytic agent"Recommendation 24 @e recommend that trane=amidacid be admini"tered a" early a" po""ible to thetrauma patient whi i" bleeding or at ri"+ of "igniFcanthemorrhage at a loading do"e of 5 g infu"ed o)er 54minute", followed by an intra)enou" infu"ion of 5 go)er J h A-rade 52?

    @e recommend that trane=amic acid beadmini"tered to the bleeding trauma patient within 6 hafter injury A-rade 5B?

    @e "ugge"t that protocol" for the management ofbleeding patient" con"ider admini"tration of the Fr"tdo"e of trane=amic acid en route to the ho"pitalA-rade 3C?

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    c CalciumRecommendation 25 @e recommend that ioni"edcalcium le)el" be monitored and maintained within thenormal range during ma""i)e tran"fu""ion A-rade 5C?

    2""ociated with increa"ed mortality a" well a" anincrea"ed need for ma""i)e tran"fu"ion

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    d 9la"maRecommendation 26 @e recommend the initial admini"trationof pla"ma A$$9 or pathogen'inacti)e pla"ma? A-rade 5B? orFbrinogen A-rade 5C? in patient" with ma""i)e bleeding;n further pla"ma admini"tered, we "ugge"t an optimal

    pla"ma:red blood cell ratio of at lea"t 5:3 A-rade [email protected] recommend that pla"ma tran"fu"ion be a)oided inpatient" without "ub"tantial bleeding A-rade 5B?

    Damage control re"u"citation acute traumaticcoagulopathy need early replacement of clotting factor

    $$9 "ource of Fbrinogen and clotting factor notha&ard freeMa=imal haemo"tatic ePect 5:3 or 6: be"ide of that,did not bring additional impro)ement

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    e $ibrinogen and cryoprecipitateRecommendation 27 @e recommend treatment withFbrinogen concentrate or cryoprecipitate in the continuingmanagement of the patient if "igniFcant bleeding i"accompanied by thromboela"tometric "ign" of a functionalFbrinogen deFcit or a pla"ma Fbrinogen le)el" of le"" than5 to 3 4 g>l A-rade [email protected] "ugge"t an initial Fbrinogen concentrate do"e of 6 to g or 4 mg>+g of cryoprecipitate, which i" appro=imatelye#ui)alent to 5 to 34 "ingle donor unit" in a 74 +g adult

    Repeat do"e" may be guided by )i"coela"tic monitoringand laboratory a""e""ment of Fbrinogen le)el" A-rade 3 C?$ibrinogen Fnal component in coagulation ca"cade,the ligand for platelet aggregation and, therefore, +eyto ePecti)e coagulation and platelet function

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    f 9latelet"Recommendation 28 @e recommend that platelet" beadmini"tered to maintain a platelet count abo)e 4 =54 K>l A-rade 5C?

    @e "ugge"t maintenance of a platelet count abo)e544 = 54 K >l in patient" with ongoing bleeding and>or B; A-rade 3C?

    @e "ugge"t an initial do"e of four to eight "ingleplatelet" unit" or one aphaere"i" pac+ A-rade 3C?

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    g 2ntiplatelet agent"Recommendation 29 @e "ugge"t admini"tration ofplatelet" in patient" with "ub"tantial bleeding orintracranial hemorrhage who ha)e been treated withantiplatelet agent" A-rade 3C?

    ;f the patient ha" been treated with acetyl"alicylicacid alone, we "ugge"t admini"tration of de"mopre"inA4,6Tg>+g? A-rade 3C?

    ;f platelet dy"function i" documented in a patient

    with continued micro)a"cular bleeding, we "ugge"ttreatment with platelet concentrate" A-rade 3C?

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    h De"mopre""inRecommendation 30 @e "ugge"t that de"mopre""inA4,6Tg>+g? be admini"tered in patient" treated withplatelet'inhibiting drug" or with )on @illebranddi"ea"e A-rade 3C?

    @e do not "ugge"t that de"mopre""in be u"edroutinely in the bleeding trauma patient A-rade 3C?

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    j .o)el anticoagulant"Recommendation 32 @e "ugge"t mea"urement of"ub"trate'"peciFc anti'factor Ha acti)ity in patient"treated or "u"pected of being treated with oralantifactor Ha agent" "uch a" ri)aro=aban, api=aban orendo=aban A-rade 3C?

    ;f bleeding i" life'threatening, we "ugge"t re)er"alof ri)aro=aban, api=aban, and endo=aban with high'do"e A3 to 4 +g? 9CC A-rade 3C?

    @e do not "ugge"t the admini"tration of 9CC inpatient" treated or "u"pected of being treated withoral direct thrombin inhibitor", "uch a" dabigatranA-rade 3B?

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    + Recombinant acti)ated coagulation factor V;;Recommendation 33 @e "ugge"t that the u"e ofrecombinant acti)ated coagulation factor V;; Ar$V;;a?be con"idered if major bleeding and traumaticcoagulopathy per"i"t de"pite "tandard attempt" tocontrol bleeding and be"t'practice u"e of con)entionalhaemo"tatic mea"ure" A-rade 3C?

    @e do not "ugge"t the u"e of r$V;;a in patient"with intracerebral hemorrhage cau"ed by i"olatedhead trauma A-rade 3C?

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    Di"cu""ion• -uideline ba"ed on critical apprai"al of the

    publi"hed literature, a re'apprai"al of therecommendation" that publi"hed 6 year" ago anda con"ideration of current clinical practice in area"

    in which RC may ne)er be performed forpractical or ethical rea"on"

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