Management of Bleeding Following Trauma

8/6/2019 Management of Bleeding Following Trauma

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MANAGEMENT OF BLEEDING

FOLLOWING TRAUMA


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Patients Demographic/

ChiefcomplaintPatients Demographic

Name: WLH

Gender: Male

Age:

Race: Chinese

Weight: 60kg

Height: 170cm

DOA: 4 May 2011

Ward: GICU

Chief complaint/ History ofpresent illness

Allegedstruck byheavy

metalobjectonabdomen

todayat 8am while working

Transferredfromaprivate

hospitalinPenang

Complainedofrightloinpain

GCS wasfull BP66/46mmHg


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Family & Social History/

Review ofSystemFamily & Social History

From China

Construction worker

Married withchildren

Non-smoker

Non-alcoholic

Review of system

BP: 99/64mmHg

PR: 94p/min

RR:40 b/min

Not known medical illness Not known drug allergy


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Diagnosis

Intraabdominalinjury

CT thorax/abdomen (doneatprivatehospital)

Grade4renalinjury

Severepancreaticheadandduodenallaceration

Pneumoperitoneum & haemeperitoneum

Fractureatleftrib Transverseprocess L1-L4fracture


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Listofoperations

Date Findings Operations

4 May 2011 Duodenalrupture,shattered

headofpancreasandright

renalinjury

Exploratorylaparatomy,closureof

duodenalendandabdominal

packing

5 May 2011 FastembolizationofGastroduodenal

artery (GDA). Inferior

pancreaticoduodenalarterynot

embolised.

5 May 2011 Bleedingfromtheheadof

pancrease (supplied byinferior

pancreaticoduodenalartery)

Pyloruspreservingproximal

pancreaticoduodenectomy

5 May 2011 Post-relaparatomyand

abdominalpacking

Exploratomylaparatomyand

abdominalpacking

7 May 2011 Relaparatomy,packremoval,

gastrojejunostomy,

cholecystojejunostomyandfeeding

jejunostomy


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SepticparametersDate BP (min) BP (max) Temp WBC Remarks

4/5 94/61 128/69 36.3 6.4 Cefoperazone 1g BD (2 dosesgiven)

changedto IV Cefepime1g TDS

Metronidazole500mg TDS

Noradrenalineinfusion wasoff.

Onlyondopamineinfusion.

5/5 106/85 130/97 36.5 2.0

6/5 103/62 123/87 37.5 5.3

7/5 119/86 152/90 38.0 8.6 Dopamineinfusion wasoff. No

inotropicsupport.

8/5 104/84 150/86 37.8 8.09/5 114/86 144/88 37.8 9.5

10/5 120/70 150/80 37.3 9.0

11/5 123/86 178/90 37.5 11.4

12/5 114/86 150/86 37.7 18.7


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Hematologyprofile

Date 4/5 5/5 6/5 7/5 8/5 9/5 10/5 11/5 12/5

WBC 6.4 2.0 5.3 8.6 8.0 9.5 9.0 11.4 18.7

Hb 6.3 7.9 11.9 11.1 11.5 12.5 11.5 12.0 12.9

HCT 19.1 23.8 34.1 32.7 34.8 37.9 35.5 37.1 39.2

Plt 108 76 49 44 71 66 66 77 145

BloodglucoseDate 4/5 5/5 6/5 7/5 8/5 9/5 10/5 11/5 12/5

RBS 14.9 4.9 6.0 6.1 6.9 9.3 8.0 8.9


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BUSE/ RenalProfile

Date 4/5 5/5 6/5 7/5 8/5 9/5 10/5 11/5 12/5 13/5

Na 144 147 142 144 147 144 144 138 140 139

K 2.9 2.4 3.7 3.9 3.9 4.1 4.2 4.2 4.3 3.6

Urea 6.4 12.1 16.2 15.7 13.4 14.8 15.9 13.0 14.2 9.5

SCr 71 135 142 127 109 86 69 53 64 47

ClCr 118.8 50.8 41.2 66.4 77.4 98.1 122.3 159.2 131.8 179.5

Cl 109 115 111 112 112 110 113 111 107 104

Ca 2.52 2.06 2.02 2.01 2.10 2.11 2.00 1.94 2.06 2.06

PO4 2.09 1.58 0.56 0.86 0.92 0.57 0.77 0.77 0.58Mg 0.74 0.49 0.8 1.03 1.04 1.10 1.05 0.9 0.97 0.91


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LiverProfile/ Cardiac

Enzymes/CoagulationProfile

Date 4/5 5/5 6/5 7/5 8/5 9/5 10/5 11/5 12/5

Albumin 19 19 23 26 23 22 23

T.

Bilirubin

18 32 93 133 170 144 127

ALT 19 629 495 388 260 177 103

ALP 33 31 93 98 93 96 94

AST 20 1079 251 94 53

CK 396 1985 2635 1451 615

LDH 249 1289 588 460 772PT 18.4 16.7 15.5 17.6 13.9 12.9 13.8 13.3 13.0

PTT 46.1 41.6 36.1 40.8 33.2 30.9 28.8 27.2 24.7

INR 1.7 1.5 1.4 1.6 1.3 1.2 1.3 1.2 1.2

Amylase 20


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ABG

Date 4/5 5/5 6/5 7/5 8/5 9/5 10/5 11/5 12/5

pH 7.19 7.40 7.40 7.38 7.29 7.41 7.40 7.39 7.43

pCO2 48 49 48 44 63 47 46 48 48

pO2 289 157 93 104 126 126 136 83 94

HCO3 18.3 30.4 29.7 26.0 30.3 29.8 28.5 29.1 31.9

BE -9.0 4.8 4.2 0.9 2.9 5.2 3.7 6.9

Lactate 6.8 2.0 2.0 1.0 0.6 1.2 1.1 1.2 1.3


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Culture & Sensitivity

Date of

Sampling

Date ofReport Source Microorganism

6/5 8/5 Trachealaspirate Nogrowth

6/5 8/5 Urine Nogrowth

9/5 10/5 Urine Nogrowth


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Medicationsin ward

Drug Date

start

Date

stop

IV Cefoperazone1g BD 4/5 4/5

IV Metronidazole500mg TDS 4/5

IV Cefepime1g TDS 4/5S/C Ocreotide0.1mgdaily 4/5

IV Factor VII 4.8mgstat 5/5 -

IV Desmopressin 20mcgstat 5/5 -

IV Tranexamicacid500mgtds 4/5 6/5

IV Tranexamicacid500mgtds 7/5 8/5

IV Vitamin K 10mgstat & OD 4/5 8/5

IV Glamin500ml OD 4/5

IV Esomeprazole40mg BD 4/5


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Medicationsin ward

Drug Date

start

Date

stop

IV N- acetylcycteine10gover1hour,

then5gover4hours,then10gover16

hours

7/5 -

IV N-acetylcycteine5g OD 4/5 8/5

IV N-acetylcycteine600mg BD 9/5

IV Magnesiumsulfate10mmol OD 5/5

IV Potassiumdihydrogenphosphate

20mmolstatthen10mmol OD

7/5 10/5

IV Potassiumdihydrogenphosphate

20mmol OD

10/5

IV Calciumgluconate1g BD 4/5 7/5

IV Frusemide 20mg TDS 4/5 6/5

IV Frusemide 20mgstat 8/8


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Medicationsin ward

Drug Date

start

Date

stop

IV Tramadol50mg TDS 10/5 10/5

IV Tramadol100mg TDS 10/5 12/5

T.Paracetamol1g TDS Withold

Cap. Celecoxib 200mg BD Withold

PCA Morphine 12/5

T. Alprazolam0.5mg ON 11/5


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DRUGRELATED PROBLEMS/DISCUSSIONS


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(1) INADEQUATE DOSE OF FACTOR VII

Pt WLH wasgiven4.8mgstatdose (wt70kgi.e.68g/kg)

Boffardetal:firstdose 200 g/kg,asecondandthird

doseof100 g/mgoneandthreehourslater1 Klitgaardetal:120 g/kg (between100and140

g/kg)and (ifrequired)asecondandthirddose2

Orlando Regional Medical Center (2008) 90g/kg

1. Boffard KD, Riou B, Warren B, ChoongPI, Rizoli S, Rossaint R, Axelsen M, Kluger Y: Recombinantfactor VIIaasadjunctivetherapyfor bleedingcontrolinseverelyinjuredtraumapatients:twoparallelrandomized,placebo-controlled,double-blindclinicaltrials.J Trauma 2005,59:815

2. Klitgaard T, Tabanera YPR, Boffard K, IauPT, Warren B, Rizoli S, Rossaint R, Kluger Y, Riou B:Pharmacokineticsofrecombinantactivatedfactor VII intraumapatients withsevere bleeding.CritCare 2006,10:R104.


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Managementofbleedingfollowingmajor

trauma:anupdated Europeanguideline 2010

rFVIIaisnotafirst-linetreatmentfor bleeding

and will beeffectiveonlyoncesourcesof

major bleedinghave beencontrolled3

InthecaseofWLH, bleedingfromtheheadof

pancrease (supplied byinferior

pancreaticoduodenalartery) notembolised

Appropriateuse? Underdose?

3. Rossaintetal. Critical Care 2010,14:R52


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rFVIIaactsonthepatient'sowncoagulation

system,thereforeadequatenumbersof

plateletsandfibrinogenlevelsareneededto

allow athrombin burstto beinduced bythe

pharmacological,supraphysiologicaldosesof

rFVIIathroughdirect bindingtoactivated

platelets.3





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rFVIIashould beconsideredonlyiffirst-linetreatment withacombinationofsurgicalapproaches, best-practiceuseofbloodproducts

(RBCs,platelets, FFPandcryoprecipitate/fibrinogenresultingin Hctabove 24%,plateletsabove50,000 109/landfibrinogenabove1.5to2.0g/l),theuseofantifibrinolyticsandcorrection

ofsevereacidosis,severehypothermiaandhypocalcaemiafailtocontrol bleeding.



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(2) Desmopressin

Desmopressin (1-deamino-8-D-arginine)enhancesplatelet

adherence,originallylicensedforuseinvon Willebrand

disease [Notto beusedroutinelyinthe bleedingtrauma

patient- onlyconsideredinrefractorymicrovascular bleeding

ifthepatienthas beentreated withplatelet-inhibitingdrugs

suchasacetylsalicylsalicylicacid (Grade 2C) 3.

Tworecentlypublishedmeta-analyses wereableto

demonstrateeitheratrendtowardsareduced bloodlossora

smallsignificantreductionin bloodtransfusionrequirements,butneitherstudycoulddemonstrateanyeffectonthecourse

ofthediseaseormortality

Possiblethromboemboliccomplicationsofthisprocoagulant

drug.


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(3) Tranexamicacid

Fibrinolyticagent

Formsareversiblecomplexthatdisplaces

plasminogenfromfibrinresultingininhibitionof

fibrinolysis;alsoinhibitstheproteolyticactivityofplasmin

Plasmahalf-life 2 hours

Suggesteddosagesaretranexamicacid10to15mg/kgfollowed byaninfusionof1to5mg/kgper

hour

10mg/kgfollowed by1mg/kgperhour


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(3) Tranexamicacidand Hematuria

Hematuriaofupperurinarytractorigin (riskof

intrarenalobstructionsecondarytoclot

retentionintherenalpelvisanduretersif

hematuriaismassive;also,ifhematuriais

associated withadiseaseoftherenal

parenchyma,intravascularprecipitationof

fibrinmayoccurandexacerbatethedisease)

http://www.drugs.com/mmx/tranexamic-acid.html


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Conclusion

Managementofbleedingisutmostimportant

intheoutcomeofatraumapatient

Guidelinesarenecessarytoensurecorrectadministrationofdrugsesp Factor VII

(expensive)


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THANK YOU


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Factor VIIaisaninitiatorofthrombingeneration. Factor VIIaactsprimarilyviatwopathwaystoactivate Factor Xa. Onepathwayisatthesiteoftissueinjurycomplexed with Tissue Factor,andtheotherisonthesurfaceofplatelets,independentoftissuefactor.

1. Factor VIIa (FVIIa)formsanactivecomplex with Tissue Factor (TF). Tissue Factorispresentinthesubendotheliallayerofthevascular wall,andhenceisnot

normallyfreetocomplex withcirculating Factor VIIa. Followinginjury,thesubendotheliumisexposedand Tissue Factorisfreeto bind FVIIa. This TF:VIIacomplexactivates Factors IX & X.

2. Factor VIIacanalsoactivatefactors IX & X ontheplateletmembrane,intheabsenceofTissue Factor. AlthoughthisisaloweraffinityreactionforgenerationofFactor Xa, Factor IXasubsequentlyactivates Factor Xaandamplifiesthispathwaydramatically. Thisreactionisoftenreferredtoasthe'Thombin Burst'andisthoughtto beresponsibleforthemajorityoffibringeneratedinresponsetoalocalinjury.

Factor Xa,complexed with Factor V formsacomplexcalledProthrombinase.ProthrombinasecleavesProthrombintoform Thrombin, whichthengeneratesFibrinfrom Fibrinogen


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Transfusedtotal16pint whole blood

3 cyclesofDIVC (FFP,plateletand

cryoprecipitate) Cryoprecipitate: Each15mL unittypically

contains100 IU offactor VIII,and 250mgof

fibrinogen. Italsocontainsvon Willebrand

factor (vWF)andfactor XIII.

FFPcontainsallclottingfactorsincludingthe

labilefactors V and VIII as wellas 250to400

mgofFibrinogen

Management of Bleeding Following Trauma

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