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Haemorrhage Control in Trauma
1. Advances
in
Modern
Trauma
Care
Haemorrhage
control.
Dr
Duncan
A.
Redmill
FCEM
Director
of
Trauma
BHSCT
Consultant
in
Emergency
Medicine
RVH.
2. Introduc@on
• Haemorrhage
30-‐40%
of
all
trauma
deaths
with
in
6
hours
• Preventable
deaths;
16%
unrecognised
or
untreated
par@cularly
in
the
abdominal
cavity
• Rx:
early
recogni@on
of
blood
loss,
rapid
control
then
restora@on
of
circula@ng
volume
3. Case
Report
• 62
yr
old
pedestrian;
struck
by
car
approx
40mph
• Spinal
immobilised,
awake,
talking,
pale.
Bruised
right
chest
and
right
hypochondrium
• RR
32
/
SPo2
93%
on
O2
via
reservoir
mask
high
flow
/
P
140
/
BP
80/55.
no
objec@ve
haemorrhage,
no
clinical
pneumothorax
/
haemothorax.
• 2L
Hartmanns
=
transient
response
• 2
units
O-‐ve
blood
from
fridge
• 1g
Tranexamic
acid
stat
/
1g
over
8hours
• CXR
–
hazy
right
lower
zone
• FAST
=
free
fluid
in
Morrisons
pouch
• CT
=
complex
lacera@on
of
liver
and
haemoperitoneum
4. Case
report
cont’d
• Ques@ons
• 1.
How
are
volume
status
and
need
for
transfusion
assessed
in
a
bleeding
pa@ent
?
• 2.
Define
Massive
Haemorrhage
• 3.
What
is
meant
by
the
term
Acute
Coagulopathy
of
trauma
shock
?
5. 1.
Volume
status
and
transfusion
need.
• 1.
Vital
signs
are
inaccurate
and
do
not
allow
accurate
determina@on
of
hypovolaemia
in
trauma
shock.
Hypotension
is
late
sign
(US
trauma
bank
mortality
at
this
stage
65%)
• Art
line
/
SPo2
or
CVo2
/
PH
/
lactate
/
BE
• Base
deficit
correlates
well
with
shock
severity
and
mortality
• Lactate
clearance
predicts
outcome
• European
Guidelines
2010
:
ini@al
fluid
crystalloid
or
colloid
target
SBP
80-‐100
mmHg,
target
Hg
7-‐9
g/dl
6. 2.
Defini@on
of
Massive
Haemorrhage
• >50%
in
3
hours
• >150ml/min
or
1.5ml/kg/min
• Cri@cal
haemorrhage
=
life
threatening
haemorrhage
that
is
likely
to
need
massive
transfusion
=
half
of
body
blood
vol
in
4hrs
or
>1
body
blood
vol
in
24hrs
7. 3.
Acute
Coagulopathy
of
Trauma
shock
• At
presenta@on
• Endothelial
injury
=
sequesters
thrombin
=
ac@va@on
of
protein
C
=
inac@vates
V
and
VIIIa
• Excessive
volume
resuscita@on
dilutes
clolng
factors
further
• Therefore
=
balanced
resuscita@on
(ATLS)
or
Damage
control
resuscita@on
8. Case
Progression
DCS
=
mesenteric
tears
/
complex
liver
lacera@ons
/
massive
haemorrhage
packs
1+2
in
theatre
/
haemorrhage
managed
by
packing
/
ICU
with
open
abdomen
covered.
• Resuscita@on
=
rewarming
/
coagulopathy
and
acidosis
10. Modern
Dilemmas
• 1.
DCS
vs
DCR
• 2.Permissive
Hypotension
vs
Head
/
spinal
injury
• 3.
1:1:1
?
• 4.
Fibrinogen
/
cfVII
/
Octaplex
/
tranexamic
acid
• 5.
CPR
in
trauma@c
arrest.
11.
12.
13. European
“Stop
the
Bleeding”
campaign.
S
:
search
for
pa@ents
at
risk
of
coagulopathic
bleeding
T
:
treat
bleeding
and
coagulopathy
as
soon
as
they
develop
O
:
observe
the
response
to
interven@ons
P
:
prevent
secondary
bleeding
and
coagulopathy
14. Recommenda@ons
• We
recommend
adjunct
tourniquet
use
to
stop
life
threatening
bleeding
from
open
extremity
injuries
in
the
pre-‐
surgical
selng
(
Grade
1B)
• Kept
in
place
@l
control
of
bleeding
achieved
• Survival
extremity
reports
up
to
six
hours
in
place.
15. We
recommend
ini@al
normoven@la@on
of
trauma
pa@ents
if
there
are
no
signs
of
ini@al
cerebral
hernia@on
(Grade
1C)
• Target
arterial
PaCo2
should
be
5
-‐
5.5
kPa
• A
low
PaCo2
on
admission
to
the
ER
is
associated
with
a
worse
outcome
in
trauma
pa@ents
16. We
recommend
that
the
Physician
clinically
assess
the
extent
of
trauma@c
haemorrhage
using
a
combina@on
of
patent
physiology,
anatomical
injury
paqern,
mechanism
of
injury
and
the
pa@ents
response
to
ini@al
resuscita@on.
• Combina@on
of
mechanism
,
RTS
,
and
response
to
ini@al
resuscita@on
• TASH
score
–
SBP
/
Hb
/
intra-‐abdominal
fluid
/
complex
long
bone
or
pelvic
#
/
HR
/
BE
/
Gender.
• Validated
with
5,834
pa@ents
on
german
registry
to
predict
individual
probability
of
massive
transfusion
and
therefore
ongoing
life
threatening
haemorrhage.
18. Whole
Body
CT
in
Adult
Trauma
-‐ ALL
Trauma
pa@ents
should
be
assessed
by
the
ED
Consultant/Senior
Doctor
-‐ Where
a
pa@ent
is
haemodynamically
unstable,
considera@on
should
be
given
to
progression
straight
to
theatre
Trauma
pa<ents
arriving
in
the
ED
who
sa<sfy
the
following
criteria
should
have
WBCT
Abnormal
Physiology
GCS
<14
SBP
<90
(sustained)
Respiratory
<10
or
>30
AND/OR
Significant
Mechanism
of
Injury
1.Blunt
-‐
Combined
velocity
>50km/hr
-‐ Motor
vehicle
crash
with
ejec@on
-‐ Motorcyclist
or
pedestrian
hit
by
a
vehicle
>30km/hr
-‐
Fatality
in
the
same
vehicle
-‐
Entrapment
>30
minutes
-‐
Fall
>3m
(>2m
in
the
Elderly)
-‐
Crush
injury
to
thorax/abdomen
-‐ Serious
mul@-‐region
assault
2. Penetra<ng
-‐ Blast
Injury
-‐ GSW
to
chest
and/or
abdomen
-‐
WBCT
may
be
requested
outwith
these
criteria
on
the
recommenda@on
of
a
senior
clinician,
special
considera@on
should
be
given
to
the
elderly
in
whom
seemingly
trivial
mechanisms
may
result
in
serious
injury.
-‐
Specific
areas
may
be
omiqed
based
on
the
recommenda@on
of
a
senior
clinician;
however
in
the
presence
of
a
significant
mechanism
clinical
assessment
may
be
wholly
unreliable.
D
Redmill,
G
Smyth,
M
Worthington,
J
Canning,
P
Chiquito-‐Lopez,
J
Millar
December
2012
19. We
Recommend
further
assessment
using
CT
for
haemodynamically
stable
pa@ents
(Grade
1B)
• FAST
:
high
specificity
low
sensi@vity
• Modern
MSCT
whole
body
scanning
reduced
to
30
secs
• Benefit
of
polytrauma
assessment
/
mul@ple
injury
iden@fica@on
• Faster
diagnosis
=
shorter
ER
/shorter
theatre
and
shorter
ICU
stay
• Ques@onable
stability
=
CXR
/
pelvis
XR
/
USS
/
+/-‐
CT
20. We
recommend
either
serum
lactate
or
base
deficit
measurements
as
sensi@ve
tests
to
es@mate
and
monitor
the
extent
of
bleeding
and
shock
• Vincent
et
Al
,
Crit
Care
Med
1983
• All
survived
:
lactate
to
normal
<
24
hrs
• 77.8%
survived
normalisa@on
within
48
hrs
• 13.6
%
survival
elevated
>
48
hrs
21. Coagulopathy
• Repeated
combined
measurements
of
PT
/
APTT
/
fibrinogen
and
platelets
• Viscoelas@c
methods
be
used
in
characterising
coagulopathy
and
guiding
therapy.
Rapid
accurate,
takes
into
account
thrombin
inhibitors
such
as
dabigitran
:
much
research
ongoing.
• Support
Tranexamic
acid
1g
stat
/
followed
by
IVI
1g
over
8
hours.
(Grade
1A).
Within
3
hours
of
injury
and
prehospital?
22. We
recommend
a
target
systolic
blood
pressure
of
80
to
90
mmHg
un@l
major
bleeding
has
been
stopped
in
the
ini@al
phase
following
trauma
without
brain
injury.
(Grade
1C)
• German
trauma
registry
17,200
mul@ply-‐
injured
pa@ents
• Coagulopathy
increased
with
increasing
preclinical
volumes
• Higher
survival
rate
in
prehospital
low
volume
resuscita@on
(<1500ml)
vs
higher
volume
• US
Trauma
data
bank
776,734
retrospec@ve
analysis
:
rou@ne
use
of
pre
hospital
IV
fluid
for
all
trauma
pa@ents
should
be
discouraged.
23. We
recommend
that
a
mean
arterial
pressure
>80
mmHg
be
maintained
in
pa@ents
with
combined
haemorrhagic
shock
and
severe
TBI
(GCS<8)
(Grade
1C)
• Both
TBI
and
spinal
injuries
• Also
elderly
and
chronic
arterial
hypertension
24. Fluid
use
• Crystalloids
in
hypotensive
bleeding
pa@ent
• Avoid
hypotonic
(Ringers)
in
head
injury
• Avoid
colloid
• Hypertonic
no
benefit
over
crystalloid
in
blunt
trauma
and
TBI
25. We
suggest
administra@on
of
vasopressors
to
maintain
target
arterial
pressure
in
the
absence
of
response
to
fluid
therapy.
(Grade
2C)
• Noradrenaline
is
the
agent
of
choice
in
sepsis
and
haemorrhagic
shock
• May
be
transiently
used
with
fluid
in
the
presence
of
life
threatening
hypotension
• Remember
target
Systolic
BP
80-‐90
mmHg
• In
presence
of
cardiogenic
involvement
inotropic
agent
such
as
epinehrine
or
dobutamine
may
be
used
26. Damage
Control
surgery
• Abdomen
early
packing
/
direct
pressure
/
aor@c
cross
clamping
• Early
pelvic
ring
closure
/
angiographic
embolisa@on
• Damage
control
methods
–
deep
haemorrhagic
shock
/
coagulopathy
/
hypothermia
or
acidosis
–
no
primary
defini@ve
management.
27. We
recommend
the
ini@al
administra@on
of
plasma
or
fibrinogen
in
pa@ents
with
massive
bleeding
(
Grade
1B/C)
• Trauma
associated
coagulopathy
25-‐30%
major
trauma
on
arrival
at
ED
• Ongoing
transfusion
RBC:FFP
ra@o
2:1
(Grade
2C)
• Early
administra@on
but
needs
to
be
thawed
28. Fibrinogen
/
Platelets
/
Calcium
• Fibrinogen
<1.5
=
fibrinogen
concentrate
or
cryoprecipitate
• Platelets
be
maintained
above
50x10(9)/L
• An@platelet
drugs
:
measure
func@on.
Limited
evidence
(2C).
Substan@al
bleeding
or
ICH
on
an@platelet
drugs
only.
Or
measured
dysfunc@on
• Maintain
Ca
levels
in
normal
range
during
massive
trnasfusion
29. PCC
• Ageing
popula@on
more
likely
Vitamin
K
antagonist
use
• INR
dependant
:
POC
tes@ng
ideal
• Aver
haemorrhage
control
achieved
early
thromboprophylaxis
during
recovery
31. CPR
in
Trauma@c
Arrest
• “Chest
compressions
in
the
Trauma
pa@ent
are
wholly
ineffec@ve,
may
cause
blunt
myocardial
injury
and
obstruct
access
for
performing
defini@ve
Manoeuvers”
Karim
Brohi
,
Professor
of
Trauma
Sciences
at
Queen
Mary,
University
of
London.
32.
33. BHSCT
Trauma
Grand
Rounds
•
•
•
•
•
•
Quality
up
to
date
teaching
Friday
7am,
Sir
Samuel
Irwin
Lecture
theatre
Breakfast
provided
Lively
discussion
Par@cipa@on
welcome
6
@mes
per
year