pre-‐hospital poc monitoring & goal directed therapy-‐debate:...
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Pre-‐hospital POC monitoring & goal directed therapy-‐debate: does it make a difference ?
Tina Gaarder, PhD, Director of Trauma, Oslo University Hospital Ullevål
Disclosures
Is there an alterna�ve to POC
for pre-‐hospital monitoring ?
What goals ?
8.4 million deaths
?
Bleeding is the major cause of acute death in trauma*
Sauaia A et al. J Trauma 1995;38:185-93 * Patients dying in hospital within 48 hours (acute deaths, n=154)
3
Evans JA et al. WJS 2010
Military vs civilian
Blast vs blunt
Evacua�on �me
Bleeding
Coagulopathy
Transfusion
The treatment of bleeding is
to stop the bleeding!
Trauma is �me
Trauma is physiology
Coagulopathy
Hypothermia Acidosis
Dilution
Dilution
+
25 %
Brohi K, et al. J Trauma 2003
Curry NS et al. Blood reviews 2012
1:1:1 ?
The treatment of bleeding is
to stop the bleeding!
Surgical disease
un�l proven otherwise
Traumekirurgisk vakt
Main principles
Minimum scene �me
External bleeding control
Op�mal triage
Minimize delay to surgical facility
Op�mal resuscita�on
MMWR 2012
Trauma
1 Physiology positive
Trauma center
1 Physiology negative
2 Anatomy positive
Trauma center
2 Anatomy negative
3 MOI positive
Acute Care hospital
3 MOI negative
4 special criteria pos
Acute care hospital
4 special criteria neg
Clinic Ac care hosp
?
CONCLUSIONS: Hypotensive resuscitation is a safe strategy for use in the trauma population and results in a significant reduction in blood product transfusions and overall IV fluid administration. Specifically, resuscitating patients with the intent of maintaining a target minimum MAP of 50 mm Hg, rather than 65 mm Hg, significantly decreases postoperative coagulopathy and lowers the risk of early postoperative death and coagulopathy. These preliminary results provide convincing evidence that support the continued investigation and use of hypotensive resuscitation in the trauma setting.
35 Morrison CA et al. J Trauma 2011
?
Tissue oxygenation
Op�mal monitoring ?
Indications
Need increases with
transporta�on /evacua�on �me
PrehospRehab
Available vs useful
‘Nice to have’ vs ‘makes a difference’
Time
Cost
Requirements
Makes a difference
Does not increase scene �me
Can be used ‘en route’
As few devices as possible
Noninvasive if possible
What do we want to achieve ?
Oxygen delivery
LSIs
External bleeding control
Airway control /cricothyroidotomy
Chest tube / thoracostomy
Iv access / fluids / transfusion
CPR / cardioversion
What ?
How ?
When ?
Vital signs
Hemoglobin
Tissue oxygena�on
Arterial blood gas
Coagula�on
Ultrasound
Vital signs
Vital signs
J Trauma Acute Care Surg. 2014
Tissue oxygenation
J Trauma Acute Care Surg. 2014
J Trauma Acute Care Surg. 2014
J Am Coll Surg 2010
MacLeod et al, J Trauma, 2003
Frith et al, J Thromb Haem 2010
”When using standard laboratory tests of coagulation, ATC should be defined as an admission PTr > 1.2”
Hb 8-‐10 g/L
INR < 1.5
Platelets > 100.000
Fibrinogen > 1.5 g/dL
Time
Only plasma factors
Boring
No ‘sexy’ graphs
1:1:1 ?
”
”Without randomized controlled trials controlling for sur-‐ vivor bias, the current available evidence suppor�ng higher plasma:erythrocyte resuscita�on is inconclusive.”
Ho, Anesthesiology, 2012
?
Platelet function Clot strength (G)
Time (min)
Ampl
ilute
(m
m)
Time
Competence
Temperature
Valida�on
Surgery 2012
?
Coagulation
Monitorering av koagulopati
Ultrasound
Indica�on – not just because you can
Limita�ons – can not exclude
Treat physiology
Pre-‐hospital POC monitoring & goal directed therapy-‐debate: does it make a difference ?
YES…provided
Mul�disciplinary system development
Avoid delay to surgery
Needs assessment
Research
Governance
The treatment of bleeding is
to stop the bleeding!