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Haemorrhage Control in Trauma

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Haemorrhage Control in Trauma

  1. 1. Advances  in  Modern  Trauma  Care   Haemorrhage  control.   Dr    Duncan  A.  Redmill  FCEM   Director  of  Trauma  BHSCT   Consultant  in  Emergency  Medicine  RVH.  
  2. 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. 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. 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. 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. 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. 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. 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  
  9. 9. Modern  Trauma  Advances  
  10. 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. 11. 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  
  12. 12. 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.  
  13. 13. 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  
  14. 14. 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.  
  15. 15. WBCT  
  16. 16. 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    
  17. 17. 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  
  18. 18. 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    
  19. 19. 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?  
  20. 20. 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.  
  21. 21. 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  
  22. 22. 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  
  23. 23. 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  
  24. 24. 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.  
  25. 25. 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  
  26. 26. 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  
  27. 27. PCC   •  Ageing  popula@on  more   likely  Vitamin  K   antagonist  use   •  INR  dependant  :  POC   tes@ng  ideal   •  Aver  haemorrhage   control  achieved  early   thromboprophylaxis   during  recovery  
  28. 28. Treatment  pathway  
  29. 29. 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.  
  30. 30. 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