1. The haemorrhaging
trauma patient
Dr Peter Sherren

2. Objectives
• Causes of coagulopathy in trauma
• Describe damage control resuscitation
• Describe new strategies for managing
traumatic haemorrhage
• Explain relevance to pre-hospital care

3. 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

4. Haemorrhage in trauma
• Surgical - Massive haemorrhage, 1 on the
floor and 4 more
• Medical - bleeding diathesis,
anticoagulants, DIC, lethal triad and ATC

6. • ~1800 pts HEMS admissions to the RLH
• ~1 in 4 pts admitted with coagulopathy
• Independent of fluid administration
• Significant association with mortality
• ATC = ACoTS

7. ATC correlates with ISS

8. Pathophysiology
• ATC ≠ DIC
• Tissue/endothelial injury and
hypoperfusion
• Increased endogenous anticoagulants
• Fibrinolysis and hyperfibrinolysis

10. • APC
• TFPI
• AT III
TERMINATION

11. Anticoagulation in ATC

12. Hyperfibrinolysis in ATC

13. 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

14. Case Presentation

15. 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

16. 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

17. 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?

18. Damage Control Resuscitation
• 3 essential components:
1. Damage control surgery
2. Haemostatic resuscitation
3. Permissive hypotension
• DCR improves outcomes and mortality.
No level 1 evidence. Cotton BA et al Ann Surg 2011

19. 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

21. 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

22. 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

23. PT & APTT?

24. 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

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

26. ROTEM (2/4) leave ED
Case - PRBCx6, FFPx4, 1g TXA, 1000 CSL, 250ml HTS

27. ROTEM (3/4) theatres
Case - PRBCx12, FFPx8, 1g TXA, 1000 CSL, 250ml HTS

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

29. Bad DCR = unfavourable
ROTEM = high mortality rate

30. 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

31. 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

32. 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!!

33. 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)

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

35. 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

36. 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 34̊C.
• Acidaemia – good resuscitation and control of bleeding is the
priority. If pH < 7.1 consider THAM/NaHCO3?

37. 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

38. 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

39. QUESTIONS?