Traumatic haemorrhage
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Transcript of Traumatic haemorrhage
The haemorrhaging trauma patient
Dr Peter Sherren
Objectives
• Causes of coagulopathy in trauma
• Describe damage control resuscitation
• Describe new strategies for managing traumatic haemorrhage
• Explain relevance to pre-hospital care
Background
• Uncontrolled haemorrhage is the commonest cause of preventable trauma deaths. Holcomb et al Ann Surg 2008.
• Damage control resuscitation (DCR) improves outcomes and mortality. Cotton BA et al Ann Surg 2011
• DCR should start at the time of injury not in the ED
Haemorrhage in trauma
• Surgical - Massive haemorrhage, 1 on the floor and 4 more
• Medical - bleeding diathesis, anticoagulants, DIC, lethal triad and ATC
• ~1800 pts HEMS admissions to the RLH• ~1 in 4 pts admitted with coagulopathy• Independent of fluid administration• Significant association with mortality• ATC = ACoTS
ATC correlates with ISS
Pathophysiology
• ATC ≠ DIC
• Tissue/endothelial injury and hypoperfusion
• Increased endogenous anticoagulants
• Fibrinolysis and hyperfibrinolysis
• APC
• TFPI
• AT III
TERMINATION
Anticoagulation in ATC
Hyperfibrinolysis in ATC
Can we predict ATC?• Several tools for predicting massive transfusion
but not validated in ATC or pre-hospital arena• Trauma Associated Severe Haemorrhage (TASH)
Score (J Trauma 2006;60:1228-1237) and others• Male• Unstable pelvic fracture• Open or deformed femur fracture• HR >120 bpm• SBP <100 mmHg• FAST positive for intra-abdominal fluid• Hb <11 g/dL• Base deficit > -2
Case Presentation
Case presentation• 16.05 – High speed MBC
• Ground crew on scene 16.18 hand over to HEMS at 16:24– M ~40 yr old male involved in high speed MBC
– I Complete traumatic Rt forequarter amputation+++blood, ?pelvis, CHI
– S Agonal breaths, SpO2 not recording, HR 160, weak/thready carotid pulse only, GCS 7→3/15, Pupils 4/4 sluggish.
– T O2 NRB, 1XIV, 500ml CSL
HEMS management• 2xIO - IV tissued• Sux only RSI - ETCO2 quantatively low but present.• Rt thoracostomy• Direct compression wound• Sam Sling• 1g TXA• 250ml HTS, 500ml 0.9%NaCl• Persistent volume issues• Depart scene 16:47 (scene time 29 mins)• Massive transfusion pre-alert, 2xPRBC given on helipad
arrival
On arrival in the ED
• AB ok
• C
– Haemodynamically unstable but volume responsive with haemostatic resuscitation with Level 1
– pH 6.7, BE -26, Lact 16
– Bloods on arrival Hb 10.6, HCT 0.28, INR 2.6 APTTR 2.1
• Taken to theatres for surgical haemostasis
• Debrief points? Good level of care?
Damage Control Resuscitation
• 3 essential components:
1. Damage control surgery2. Haemostatic resuscitation
3. Permissive hypotension
• DCR improves outcomes and mortality. No level 1 evidence. Cotton BA et al Ann Surg 2011
1. Damage Control surgery• Unstable patients with major trauma do not
survive prolonged definitive surgery• Normalise physiology at expense of anatomy
• Stop haemorrhage (Packing, clamping, resection +/- IR)• Minimise contamination • Limb saving procedures• Good wash out of cavities• Drains and low threshold for Laparostomy• Definitive surgery another day
• Optimise lethal triad on the ICU
2. Haemostatic resuscitation• Aggressive and simultaneous management of the
lethal triad and ATC in major trauma• Minimise Crystalloid transfusion, NO COLLOID.• PRBC - HCT~0.5-6 & K+ 10-40mmol/L. Important for oxygen
carriage and volume.• FFP – FII, V, VII-XII, fibrinogen, vWF and ATIII• Platelets • Cryoprecipitate – fibrinogen, FVIII, FXIII and vWF• Ideal PRBC:FFP:platelet ratio not clear but should be <2:1:1
• Use of adjunctive therapies• Tranexamic acid Crash 2, NNT 67→ lower with MT&SBP<75• Calcium vital for clotting, +ve inotrope & myocardial protection
Blood component therapy problems• When reconstituted poor
relative of fresh whole blood• Time to thaw• Reduced 2,3 DPG levels and
O2 carrying ability• Short shelf life• High volume and antigenic
load -> ARDS/SIRS/ACS• ABO issues• Finite resource• Citrate load• Viral/bacterial contamination• Transfusion reactions
PT & APTT?
ROTEM• Rotational viscoelastive
test
• NPT
• Whole blood
• Rapid
• Functional/dynamic vs quantative lab test
• Clotting factors, fibrinogen&platelets
• CA5 ≤35mm predictive of ATC and MT, Davenport et al Crit Care Med 2011
ROTEM on ED admission (1/4)Case - 2u PRBC, 1g TXA, 500ml CSL, 250ml HTS
ROTEM (2/4) leave EDCase - PRBCx6, FFPx4, 1g TXA, 1000 CSL, 250ml HTS
ROTEM (3/4) theatresCase - PRBCx12, FFPx8, 1g TXA, 1000 CSL, 250ml HTS
ROTEM 4/4- Good DCR and patient survival Case - PRBCx23, FFPx16, 2g TXA, Cyro/Platx3, CaCL 3g, 1000ml CSL, 250ml HTS -> HAEMOSTASIS
Bad DCR = unfavourable ROTEM = high mortality rate
3. Permissive hypotension• Titrated volume resuscitation to maintain organ viability
and not normality until haemorrhage is controlled
• First clot is often the best = preserve it• Aggressive early fluid resuscitation in penetrating trauma
with uncontrolled bleeding may be detrimental, Bickell WH N Engl J Med 1994.
• Poor evidence to inform resuscitation strategies in blunt trauma with uncontrolled bleeding
• The evidence for maintaining CPP in head injuries is much stronger
• ATLS provides a framework for those who are not experts in trauma
Permissive hypotension
• The end points for resuscitation will depend on age, premorbid autoregulatory state and acute pathology
• ‘Rule of thumb’ resuscitation end points:• Penetrating trauma - maintain cerebration or central pulse or
SBP~60mmHg
• Blunt trauma – maintain radial pulse or SBP >80mmHg
• Head injury – maintain temporal pulse or SBP >100mmHg
• SCI – Spinal cord perfusion can be improved with SBP>90mmHg, but no functional outcome data as yet
The future for DCR
• PCC (FII, VII, IX and X) in non-warfarin pts. Joseph B et al, J Trauma Acute Care Surg 2012 & Schochl H et al, Crit Care
2011.
• FDP – French military and porcine models• FCC (fibrinogen and FXIII) over
cryoprecipitate. Schochl H et al, Crit Care 2010 and 2011
• rFVIIa out of favour
• Fresh warm whole blood, I wish!!
The future for DCR• Alkalising agents – Tris-hydroxymethyl
aminomethane (THAM) in MT with severe acidaemia
• Novel hybrid resuscitation strategies. Doran CM et al, J Trauma Acute Care Surg 2012
• High flow/low pressure resuscitation – endothelial resuscitation and microvascular washout, Richard Dutton
• Suspended Animation• Platelet function - validation of platelet mapping and
aggregometry vs traditional PF-100• Use of thromboelastometry (TEG/ROTEM)
Early and individualized goal-directed therapy for TICSchöchl H et al. Scand J Trauma Resusc Emerg Med 2012
Pre-hospital Management• C-ABCDE/MARCH – Tourniquets, Haemostatic agents, foley
catheter• Meticulous DCR
• DCS is the key critical intervention so limit scene time• Haemostatic resuscitation – Early use of PRBC, TXA and for the future
PCC/FCC/FDP/alkalising agents• Permissive hypotension - good individualised endothelial resuscitation
• Lethal triad management• Hypothermia- Limit exposure, Enflow fluid warmer, HMEF, insulation and
active warming pads in cold climates.• Acidaemia- A/w further evidence for alkalising agents and high flow/low
pressure resuscitation.• Coagulopathy- Limit crystalloid resuscitation
• Pre alert MTC of need for MT protocol activation
Additional Hospital management• DCR
• Damage control surgery• Haemostatic resuscitation
– Initially protocolised <2:1:1 ratios of PRBC:FFP:platelets with fibrinogen supplementation.
– Adjuncts: TXA, Calcium and consider alkalising agents– Viscoelastive NPT to guide on going transfusions
• Permissive hypotension until haemorrhage control
• Lethal triad• Hypothermia – ↑ambient temperature, active warming/forced air
warmers, radiant heaters. Temp no lower than 34WC.• Acidaemia – good resuscitation and control of bleeding is the
priority. If pH < 7.1 consider THAM/NaHCO3?
Future for GSA-HEMS• Haemostatic agents – Hemcon and Quikclot → Combat
gauze, ChitoGauze and Celox
• Foley catheters
• MAT → SOF tactical tourniquet
• TXA – part of Victorian trial or introduce?
• PCC – for warfarin + ATC?
• State wide pre-alert for MTC (Code Crimson) – SOP? • sBP<90 • Unresponsive to resuscitation • With active bleeding• E-FAST +ve
• Good temp control – EnFlow & improved packaging
Summary• Early coagulation dysfunction is common in
trauma patients with haemorrhagic shock
• Tailored management of the ‘lethal triad’ and ATC is essential
• DCR is an emerging standard of care, however, some of its components are pushing the boundaries of what is good EBM
QUESTIONS?