1. TRAUMA
Holger Baumann MD
vooruitstrevend in perioperatieve zorg
afdeling Anesthesiologie

2. WHY TRAUMA?
Number 1 Killer
40 % uncontrolled hemorrhage
25 % coagulopathic in the ED
Krug, Am J Public Health 2000
Sauaia, J Trauma 1995
Brohi, J Trauma 2003
Maegele Shock 2006

3. Trauma & Coagulopathy
Brohi, Curr Opp Crit Care 2007
Frith, J Thromb 2010

4. STOP The Bleeding Campaign
S creen for risk of bleeding/coagulopathty
T reat bleeding coagulopathy
O bserve response to intervention
P revent secondary bleeding / coagulopathy
Rossaint, Crit Care 2013
www.advancedbleedingcare.org

5. STOP The Bleeding Campaign
Screen:
Scores Labor
Treat:
FFP Fibrinogeen TRX
PCC rFVIIa
Observe:
PT aPTT ROTEM/TEG
Prevent:
Preconditions

6. Screen for risk of bleeding/coagulopathy
SCORES:
SCORES:
ABC
TASH
Penetrating mechanism
ED SBP <90 mm
ED HR >120/min
Positive FAST
Nunez, J Trauma 2009
Cotton J Trauma 2010
Krumrei J Trauma 2012
Yucsel J Trauma 2006

7. Trigger for MT
OR for MT 24
INR>1,5
SBP < 90
mmHg
Hb < 6,6 mml/l
BD > 6,0
HR > 120 bpm
Penetrating
dFAST +
OR MT 24 +
hemorrhagic death
OR MT 6 +
hemorragic death
2,2
2,5
3,9
1,9
1,7
1,5
1,8
1,8
1,1
1,0
1,9
1,8
2,0
1,2
0,9
1,8
Modified from
2,0
3,0
1,2
1,2
1,9
Calcutt, J Trauma 2013 (PROMMT)

8. MTS ≥ 2
MT 24
MT 24
MT 6
+ hemorrhagic death
+ hemorrhagic death
Sensitivity %
85
85
90
Specificity %
41
41
39
PPV %
31
33
39
NPV %
89
89
95
OR MT
3,9
3,9
6,0
Modified from
Calcutt, J Trauma 2013 (PROMMTT)

9. Base Deficite 1C
BD <=
2
Blood
products
TASH Score
Mortality %
Action?
BD >2 6
BD >610
BD> 10
1,5
4,5
10,3
20,3
3,5
7,4
6,1
12
10,6
23
14,3
51,3
Act
Prepare
MTP
Watch Consider
modified
Rec 11 Mutschler, Crit Care 2013

10. Shock Index ?
BD≤2
SI < 0,6
BD>2-6,0 BD>6,0-10,0 BD<10,0
SI 0,6-1,0
SI 1,0-1,4
SI ≥ 1,4
BD≤2
SI < 0,6
BD>2-6,0 BD>6,0-10,0 BD<10,0
SI 0,6-1,0
SI 1,0-1,4
SI ≥ 1,4
modified
Mutschler, Crit Care 8- 2013

11. Conventioneel Lab. vs POC
Standard-Lab
Point of Care
(ROTEM/TEG)
NO
YES
30-60 min.
5-15 min.
Hyperfibrinolyse
NO
YES
Sterkte van stolsel
NO
YES
Evaluatie voor bloeding
Tijd tot uitslag

12. Conventioneel Lab. vs POC
Standard-Lab
Point of Care
(ROTEM/TEG)
NO
YES
30-60 min.
5-15 min.
Hyperfibrinolyse
NO
YES
Sterkte van stolsel
NO
YES
Evaluatie voor bloeding
Tijd tot uitslag
Logistics?
Resources?
Costs?
QA?
Training?

13. POC - thrombo…..
•
Admission Rapid Thrombelastography Can Replace Conventional Coagulation Tests
in the Emergency Department Experience With 1974 Consecutive Trauma Patients
•
Trauma Bleeding Management: The Concept of Goal-Directed Primary Care / schochl
•
Screenshots artikel / literture unten diskussion

14. Monitoring:
..routine practice include the measurement of INR, APTT, fibrinogen and platelets.
INR and APTT alone should not be used to
guide haemostatic therapy.
1C
.. ..Thrombelastometry to assist in guiding
haemostatic therapy.
2C
modified
Rec 12 Spahn, Crit Care 2013

15. Holcomb, Ann Surg
2012

16. FIB. - CRYO - FFP
Fibrinogen
Content Fib.
FFP
PCC
constant
inconsistent
constan
Time admission Immediately 30 min.
Immediate

17. FFP’s – R24
Early treatment with thawed FFP in patients
with massive bleeding. Initial dose is 10 to
15 ml/kg.
1B
Spahn, Crit Care 2013

18. PCC
+
-
Rapid reversal of INR
Verschillende concentraten
Small volume
Prothrombotic risk ( 1,8%*)
No blood type matching
No volume effect
Allercig effects?
*Dentali Thrombosis Hemost. 2011

19. PCC
Emergency reversal of Vit. K-dependent oral
anticoagulants.
1B
..PCC ..in the bleeding patient with
thromboelastic evidence of delayed
coagulaton ininiation.
1C
Rec 31 Spahn, Crit Care 2013

20. Tranexminezuur (TRX)

21. Tranexminezuur (TRX)
..as early as possible to the bleeding patient
1A
..within 3 h after injury
1B
Consider TRX en route to the hospital
1C
Rec 31 Spahn, Crit Care 2013

23. Observe Response to Intervention
• Clinical
• ROTEM
•

24. Prevent secondary coagulopathy
•
•
•
•
Damage control
Rewarming
Restore physiology
No delay

26. ‘De drie eenheid’

27. Whole blood Bloedprodukten
Hemodilutie - – 1:1:1 approach
650 ml koud spul
Hb 5.5 mmol/l (8.9 g/dl)
Thr. 75 * 109
Plasma factors 70 %
Fibrinogen: 0,5 -1 g (?)
500 mL Warm
Hct: 38-50%
Plt: 150-400K
Coags: 100%
1500 mg
Fibrinogen
Armand, Transf Medicine Reviews 2003
Como, Transfusion 2004

28. Massaal bloedtransfusie protocol @

29. How do u sweet’n your coffee?

30. rFVIIa in Trauma
Consider rFVIIa after “conventional” therapy,
if
pH > 7,2
Temp. > 35,0C
Fibrinogen > 100 mg/dl or FIBTEM >12 mm
Thrombocytes > 50/nl or Extem > 45mm
Hyperfibrinolysis ruled out/therapy
No surgical/IR therapy
rFVIIa(Novoseven): 90micg/kg BW
2C
REC 33: Spahn, Crit Care 2013

31. A failure in planning is a plan for failure
S03E08 Star Wars The Clone Wars
Zorg voor heldere lokale protocollen.
Multidisciplinaire aanpak
Voorlichting en training
Behandel coagulopathieën
•
•
•
•
•
Basale behandeling
TRX
FFP/FIB
MTP
rFVIIa

32. En nu?

33. Fibrinogen / Cryoprecipitate
Recommendation 26. We recommend treatment with
fibrinogen concentrate or cryoprecipitate if significant
bleeding is accompanied by thrombelastometric signs of a
functional fibrinogen deficit or a plasma fibrinogen level of
less than 1.5 to 2.0 g/l (Grade 1C).
No trauma trials - extrapolation from haemophilia and
congenital afibrinogenaemia
Probably give if fibrinogen < 1 g/l
Dose - know your local formulation (cryo not licensed
outside UK). Enoughin perioperatieve zorg
vooruitstrevend to give > 1 g/l
afdeling Anesthesiologie

34. Recommendation
RBC’s
ATIII
Hb 4,4-5,6 mmol/l
No
1C
1C
17
26
DDAVP
Not routinely
2C
30
> 50000
Platelets
> 100000 in TBI
1C
2C
28
Calcium ≥ 1,0 mmol/l
1C
25