traumatic haemorrhage

41
The haemorrhaging trauma patient Dr Peter Sherren Senior registrar Anaesthesia, Intensive Care and Pre-hospital care The Royal London Hospital and Greater Sydney Area HEMS

Upload: pbsherren

Post on 02-Nov-2014

570 views

Category:

Documents


1 download

DESCRIPTION

 

TRANSCRIPT

Page 1: Traumatic haemorrhage

The haemorrhaging trauma patient

Dr Peter Sherren

Senior registrar Anaesthesia, Intensive Care and Pre-hospital care

The Royal London Hospital and Greater Sydney Area HEMS

Page 2: Traumatic haemorrhage

Objectives

• Causes of coagulopathy in trauma

• Describe damage control resuscitation

• Describe new strategies for managing traumatic haemorrhage

• Explain relevance to pre-hospital care

Page 3: Traumatic haemorrhage

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

Page 4: Traumatic haemorrhage

Haemorrhage in trauma

• Surgical - Massive haemorrhage, 1 on the floor and 4 more

• Medical - bleeding diathesis, anticoagulants, DIC, lethal triad and ATC

Page 5: Traumatic haemorrhage
Page 6: Traumatic haemorrhage

• ~1800 pts HEMS admissions to the RLH• ~1 in 4 pts admitted with coagulopathy• Independent of fluid administration• Significant association with mortality• ATC = ACoTS

Page 7: Traumatic haemorrhage

ATC correlates with ISS

Page 8: Traumatic haemorrhage

Pathophysiology

• ATC ≠ DIC

• Tissue/endothelial injury and hypoperfusion

• Increased endogenous anticoagulants

• Fibrinolysis and hyperfibrinolysis

Page 9: Traumatic haemorrhage
Page 10: Traumatic haemorrhage
Page 11: Traumatic haemorrhage

• APC

• TFPI

• AT III

TERMINATION

Page 12: Traumatic haemorrhage

Anticoagulation in ATC

Page 13: Traumatic haemorrhage

Hyperfibrinolysis in ATC

Page 14: Traumatic haemorrhage

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

Page 15: Traumatic haemorrhage

Case Presentation

Page 16: Traumatic haemorrhage

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

Page 17: Traumatic haemorrhage

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

Page 18: Traumatic haemorrhage

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?

Page 19: Traumatic haemorrhage

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

Page 20: Traumatic haemorrhage

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

Page 21: Traumatic haemorrhage
Page 22: Traumatic haemorrhage

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

Page 23: Traumatic haemorrhage

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

Page 24: Traumatic haemorrhage

PT & APTT?

Page 25: Traumatic haemorrhage

PT & APTT?

Page 26: Traumatic haemorrhage

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

Page 27: Traumatic haemorrhage

ROTEM on ED admission (1/4)Case - 2u PRBC, 1g TXA, 500ml CSL, 250ml HTS

Page 28: Traumatic haemorrhage

ROTEM (2/4) leave EDCase - PRBCx6, FFPx4, 1g TXA, 1000 CSL, 250ml HTS

Page 29: Traumatic haemorrhage

ROTEM (3/4) theatresCase - PRBCx12, FFPx8, 1g TXA, 1000 CSL, 250ml HTS

Page 30: Traumatic haemorrhage

ROTEM 4/4- Good DCR and patient survival Case - PRBCx23, FFPx16, 2g TXA, Cyro/Platx3, CaCL 3g, 1000ml CSL, 250ml HTS -> HAEMOSTASIS

Page 31: Traumatic haemorrhage

Bad DCR = unfavourable ROTEM = high mortality rate

PRBC 21u

Page 32: Traumatic haemorrhage

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

Page 33: Traumatic haemorrhage

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

Page 34: Traumatic haemorrhage

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• MP40X – Phase IIa. Brohi et al. Crit Care Med 2010

• Fresh warm whole blood, I wish!!

Page 35: Traumatic haemorrhage

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• Intra-aortic balloon tamponade

• Platelet function - validation of platelet mapping and aggregometry vs traditional PF-100

• Use of thromboelastometry (TEG/ROTEM)

Page 36: Traumatic haemorrhage

Early and individualized goal-directed therapy for TICSchöchl H et al. Scand J Trauma Resusc Emerg Med 2012

Page 37: Traumatic haemorrhage

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

Page 38: Traumatic haemorrhage

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?

Page 39: Traumatic haemorrhage

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

Page 40: Traumatic haemorrhage

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

Page 41: Traumatic haemorrhage

QUESTIONS?