1. PATHO-PHYSIOLOGY
(& MX) OF TRAUMA
Dr Aoibhin Hutchinson
27th September 2013
Monday, 21 October 13

2. THE REAL
TRAUMA INTERFACE
Monday, 21 October 13

3. TRAUMA LOGISTICS
Monday, 21 October 13

4. MAJOR TRAUMA CENTRE
• 24
hours a day, fully staffed ED
• Consultant
led trauma team
• Dedicated
trauma theatres & operating lists
• All
major specialties:
• Ortho, general, vascular, neuro, plastics, cardiothoracic, head
& neck, urology
• Interventional
• Anaesthesia
Monday, 21 October 13
radiology
& Critical care

5. • High
volume trauma centres reduce mortality from
major injury by 50%. 1
•
(high volume > 20 cases per week)
• Time
from trauma to definitive surgery /
intervention is the primary determinant of
outcome in major trauma (not time to ED). 2
1. Relationship Between Trauma Center Volume and Outcomes. Nathens A et al, JAMA. 2001;285:1164-1171
2. Resources for Optimal Care of the Injured Patient. American College of Surgeons, 1999
•
Monday, 21 October 13

6. Monday, 21 October 13

7. Jim McGuigan
Thoracic Surgeon
Royal Victoria Hospital
Belfast
Monday, 21 October 13

8. Monday, 21 October 13

9. Monday, 21 October 13

10. ATLS
Monday, 21 October 13

11. Monday, 21 October 13

12. No
major
changes
to
thoracic
Though
role
of
US
Monday, 21 October 13
No
springing
pelvis
Binder
on
early
Pan
scan
Use
of
focused
ECHO
/
US

13. SURVIVING
TRAUMA
•Early patho-physiology:
•Immediate threat to life
•ABC
•Longer term patho-physiology:
•Surviving critical care
(prolonged care phase)
•MOF / Sepsis
Monday, 21 October 13
ATLS: Trimodal death distribution

14. AIMS
1.What’s important in the early
resuscitative phase?
2.What important in the critical
care in recovery phase?
Monday, 21 October 13

15. BASIC TRAUMA
PATHO-PHYSIOLOGY
in a word - bleeding
Monday, 21 October 13

16. •Define shock
....an abnormality of the circulatory system
that results in inadequate organ perfusion and
delivery of oxygen
•Classify shock
•Haemorrhagic / hypovolaemic
•Cardiogenic
•Obstructive
•Distributive
•Septic
•Neurogenic
Monday, 21 October 13

17. CO = HR x SV
BP = CO x SVR
Monday, 21 October 13

18. BLEEDING...
Clinically:
Blood%loss%
•Tachycardic
Decreased%IV%volume%
•Hypotensive
Reduced%venous%return%
(preload)%
•Narrow pulse pressure
•Cold peripheries / shut
down
Decreased%stroke%volume%
Lowered%CO%
Reduced%BP%%
Hypoperfusion%of%Assues%
Compensatory
• Increase SVR
• Increase HR
To preserve CO / BP
Monday, 21 October 13
Tissue%hypoxia%
MODs%

19. MANAGEMENT AIMS
Control the bleeding
Correct coagulopathy
Restore IV volume
Preserve organ perfusion
Monday, 21 October 13

20. WHAT’S NEW?
Monday, 21 October 13

21. Triad of Death
1.Coagulopathy
2.Acidosis
3.Hypothermia
Vicious circle
rather than a triangle
SIRS
CARS
Acute Traumatic
Coagulopathy
25% trauma pts have established coagulopathy (ATC) on presentation
- 4 fold increase in mortality
Brohi K, Singh J, Heron M, Coats T. Acute traumatic coagulopathy. J Trauma 2003;54:1127-30.
MacLeod JB, Lynn M, McKenney MG, Cohn SM, Murtha M. Early coagulopathy predicts mortality in trauma. J Trauma 2003;55:39-44.
Maegele M, Lefering R, Yucel N, Tjardes T, Rixen D, Paffrath T, et al. Early coagulopathy in multiple injury: an analysis from the German Trauma
Registry on 8724 patients. Injury 2007;38:298-304.
Monday, 21 October 13

22. WHAT’S
‘RELATIVELY’
NEW?
•Fluid resuscitation
•Permissive hypotension
•Haemostatic resuscitation
•Blood product administration
ratios
•Military approach: Damage
control resuscitation
•Tranexamic acid
•Damage control Sx
•Interventional radiology
Monday, 21 October 13

23. AKI
Monday, 21 October 13
Mortality

24. FLUIDS
 Increasing
evidence for crystalloid
 Hyperoncotic
Colloid:
 Increased risk AKI
6S STUDY
 Increased mortality
CHEST STUDY
Monday, 21 October 13

25. •
June 20th 2013: Joint position statement from FICM, RCOA, ICS, College of EM following
on from European Medicines Agency suspending marketing authorisation for HES due to
risks outweighing any perceived benefits
•
Applies equally to pts with hypovolaemia, hypovolaemic shock, critically ill patients
including those with sepsis, burns, trauma and those undergoing surgery
Monday, 21 October 13

26. EMA DECISION BASIS
•1. Perner A, Haase N, Guttormsen AB, et al. Hydroxyethyl starch
130/0.42 versus Ringer's acetate in severe sepsis. N Engl J Med
2012;367:124-34. (6S Study)
•2. Brunkhorst FM, Engel C, Bloos F, et al. Intensive insulin therapy and
pentastarch resuscitation in severe sepsis. N Engl J Med
2008;358:125-39. (VISEP study)
•3. Myburgh JA, Finfer S, Bellomo R, et al. Hydroxyethyl starch or saline
for fluid resuscitation in intensive care. N Engl J Med 2012;367:1901-11.
(CHEST Study)
Monday, 21 October 13

27. Monday, 21 October 13

28. PERMISSIVE HYPOTENSION
•
Fluid resuscitating
•
a patient who is no longer bleeding is easy
•
a patient with ongoing bleeding is much more
complicated: huge potential to make the patient worse your endpoints are much more important
•
Increasingly accepted view that moderate hypotension
(Systolic <90mmHg) in trauma patients without TBI is
sufficient to maintain critical organ perfusion (but pressure =
flow)
•
Resuscitating to >90mmHg runs the risk of clot dislodgment
& vicious circle formation
Monday, 21 October 13

29. NOT SO NEW?
Monday, 21 October 13

30. Monday, 21 October 13

31. Monday, 21 October 13

32. NICE 2004 : PRE HOSPITAL
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33. Monday, 21 October 13

34. RESUSCITATION OF THE
BLEEDING PATIENT
•
Rather than aggressive fluid replacement, the ability to
control ongoing blood loss is one of the most
important determinants in the outcome of a seriously
injured patient.
Hess JR, Holcomb JB, Hoyt DB: Damage control resuscitation:
The need for specific blood products to treat the coagulopathy of trauma.
Transfusion 2006;46:685-6.
Don’t obsess about fluid resuscitation
....control the source of bleeding
Monday, 21 October 13

35. RESUSCITATION
•
Coapulopathy (ATC) occurs much earlier than we thought & is
a major driver
•
Haemorrhage control is the priority
•
Do not delay transfer to place of definitive control transfer but
use with caution
•
Permissive hypotension - arguable for - really relevant to
prehospital
•
Clinical end points of resuscitation are uncertain - we are stuck
with BP (Sys 100; Hb 7-8; plts100; INR<1.5; fibrinogen>1)
Monday, 21 October 13

36. BLOOD
-HAEMOSTATIC RESUS
-MASSIVE TRANSFUSION
-BLOOD PRODUCT RATIOS
Monday, 21 October 13

37. MASSIVE TRANSFUSION
•
emerging opinion that
massive transfusion of red
cells and clotting factors in
trauma patients should be
given in broadly similar
proportions from the
outset
Borgman MA, Spinella PC, Perkins JG, Grathwohl KW, Repine T, Beekley AC, et al.
The ratio of blood products transfused affects mortality in patients receiving massive transfusions
at a combat support hospital. J Trauma 2007;63:805-13.
Monday, 21 October 13

38. PRBC : FFP : PLTS: CRYO
Borgman MA, Spinella PC, Perkins JG, Grathwohl KW, Repine T, Beekley AC, et al.
The ratio of blood products transfused affects mortality in patients receiving massive transfusions
at a combat support hospital. J Trauma 2007;63:805-13.
Monday, 21 October 13

39. Monday, 21 October 13

40. DILUTIONAL
COAGULOPATHY
Monday, 21 October 13

41. ACUTE TRAUMATIC COAGULOPATHY (ATC) &
TRAUMA INDUCED COAGULOPATHY (TIC)
Monday, 21 October 13

42. DIAGNOSING
ATC
•It is a nightmare.....blind
•PT & APTT - only describe isolated fragments
of the haemostatic process
•Always delays
•Next set sent before first set back
•If it were easy & quick - decisions about blood
product ratios would not have to be preemptive
Typical example of time to receiving PT result
Monday, 21 October 13

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48. TRANEXAMIC ACID
Monday, 21 October 13

49. TRANEXAMIC ACID
•
Direct trauma causes activation of fibrinolysis
•
CRASH 2 June 2010, The Lancet
•
Over 20,000 pts; 274 hospitals, 40 countries
•
Admin <8hrs from injury:1gm over 10mins & then 1gm
over 8hours
•
Administration of Tranexamic acid reduced the risk of
death in bleeding trauma victims (14.5% vs 16%)
•
No increase in vascular occlusive events
Monday, 21 October 13

50. June 2010
March 2011
Monday, 21 October 13

51. TRANEXAMIC TIMING
• Early
Rx <1hr from injury:
• Mortality
• Rx
1-3hrs from injury:
• Mortality
• Rx
due to bleeding 5.3% (vs 7.7% placebo)
due to bleeding 4.8% (vs 6.1% placebo)
> 3hrs from injury:
•
Seemed to increase risk of death due to bleeding 4.4%
(vs 3.1% placebo)......Unclear why
Monday, 21 October 13

52. CRASH 2 - TIMING
Monday, 21 October 13

53. TRANEXAMIC ACID
•
In bleeding trauma victims: Give it!
•
CRASH 2: 32% reduction in death if given <1hr
•
Give it ASAP (<3hrs) :1gm over 10mins (followed by 1gm
over 8hrs)
•
Given early it effects ATC: prevents full activation of fibrinolysis
which once started is difficult to abate
•
Pre hospital care may be where its role is best placed
•
Caution in those who present several hours after injury
Monday, 21 October 13

54. LESSONS FROM
CONTMEPORARY WAR
• Transfusion policies
•Rx blast injury
• Liberal use of tourniquets
•Use of haemostatic
•Joint theatre system
•Critical care air transport
team
•Use of US & IO needles
Monday, 21 October 13
dressings
•PTSD

55. MILITARY APPROACH
• Definitive
care quickly
• Permissive
• Early
hypotension
administration of blood:
• Haemostatic
• High
resus
ratio PRBC : FFP : Plts
• Tranexamic
• Damage
acid
control resuscitation
& surgery (DCR / DCS)
Monday, 21 October 13

56. DIFFERENCES
• Military
• Pre
Mx
& non military
hospital & In hospital
• Penetrating
injuries
• Patients-
Monday, 21 October 13
/ blunt / blast
demographics

57. INCOMPLETELY ANSWERED
QUESTIONS
•
Which patients would benefit most from haemostatic resus?
•
How do we identify them at the outset?
•
What is the optimal ratio PRBCs : FFP : Plts ?
•
Which pts will benefit most from permissive hypotension?
•
Precise indications for recombinant factor VII, tranexamic, cryo,
calcium?
•
Does the storage age of the blood matter?
Monday, 21 October 13

58. CONCLUSION
•
Trauma is a leading cause of death in young people: haemorrhagic shock is the leading
cause of mortality
•
Control of bleeding is paramount: therefore rapid transfer is a priority
•
Permissive hypotension has a role in pre hospital care
•
Coagulopathy develops early & is an independent risk factor for death - aggressive Mx
•
Tranexamic acid should be given early - ideally pre hospital
•
Lessons to be learnt from Military approach - but be objective: different patients, injuries &
situation
•
Haemostatic resus: high ratio of products needed; likely 1:2; who stands to benefit most?
•
Further Evidence base is required
Monday, 21 October 13

59. AIMS
1.What’s important in the early
resuscitative phase?
2.What important in the critical
care in recovery phase?
Monday, 21 October 13

60. • Trauma
World
is a major cause of mortality in <50yrs in Western
• Mortality
due to sustained injuries (early)
• Subsequent
• About
Monday, 21 October 13
immune reactions (late) & resultant MOF
5% trauma patients develop post traumatic MOF

61. TRAUMA & MOF
Endogenous factors susceptibility to MOF
•genetics
•physical condition
Exogenous factors
•Injuries themselves
(1st hit: trauma load)
•Resuscitation strategy &
Surgery
(2nd hit: intervention load)
Organ damage & then failure is due to dysfunctional immune response
Monday, 21 October 13

62. Monday, 21 October 13

63. SIRS
• Fever
>38 or <36
• HR
>90
• RR
>20 or PCO2 < 4.3kPa
• WC
>12 or <4
or > 10% immature bands
Monday, 21 October 13
Precipitants:
• Tissue injury
• Hypoxia
• Hypovolamia
• Hypercarbia
• Infection

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68. PROPHYLAXIS
• Address
nutritional needs
• Preventing
ulceration
stress bleeding, venous thrombosis & pressure
• Assessing
antimicrobial prophylaxis, tetanus status & preventing
• Consider
LPV
HCAIs
• FAST
Monday, 21 October 13
HUG

69. OTHER TOPICS TO MENTION
• Hypothermia
• EPO
in trauma?
• Statins
Monday, 21 October 13
in trauma?
in trauma?