Glomerular Filtration and determinants of glomerular filtration .pptx
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
