2. Vital Part of Damage control resuscitation in Haemorrhagic shock
1] Permissive Hypotension[Minimal Normotension]
2] Haemostatic Resuscitation [ Massive Transfusion Protocol]
3] Anatomical Haemorrhage control [ Damage control surgery ]
3. Hemostatic resuscitation –
process of restoring and sustaining normal tissue perfusion in uncontrolled
hemorrhagic shock, with preservation of effective clotting
until definitive anatomic control of hemorrhage is achieved, typically through surgery or
angiographic embolization
Continued processes in a Patient with severe trauma
4. Major causes of death in trauma
Traumatic Brain injury- Common –Determined at the time of injury
Haemorrhage 40%- common and preventable
contributing causes for Shock in trauma
-Obstructive [tension pneumothorax and cardiac tamponade]
-Distributive shock [High spinal cord injury]
-Cardiac contusions/dysfunction
5. Injury associated Coagulopathy
1]Lethal Triad
Coagulopathy-Dilutional-Fluids or unbalanced blood products , DIC
Hypothermia- Exposure and Fluid administration
Acidosis- Tissue injury and shock
2]Acute Traumatic Coagulopathy
3]Microparticle release and platelet dysfunction
4]Ongoing losses
6. Acute Traumatic coagulopathy
impairment of hemostasis and activation of fibrinolysis that occurs early after injury
in the absence of thrombocytopenia and hypofibrinogenemia
biochemically evident prior to, and independent of, the development of significant
acidosis, hypothermia, or hemodilution
INR > 1.5
Thought secondary to significant activation of protein C
Inactivates Va and Viiia –Inhibiting X and Thrombin
4 fold increase in mortality
1-4 pts in every 10 patients with major trauma
7. Lethal triad
Coagulopathy – ATC , 10% reduction in clotting factors for every 500ml
blood loss replaced by crystalloids/PRBC, DIC
Acidosis – markedly reduce activity of V11 , Xa and Va
Hypothermia - massive bleeding in conjunction with a core temperature of
<30°C is rarely survived . Secondary to platelet dysfunction –starts < 34 °C
and reduce CF function
9. Guiding principles for resuscitation
Resuscitation using IV fluids -only for hypotensive patients, only until
blood is available – To minimal Normotension
Blood products -as soon as the need for transfusion is recognized
Blood products should be given in equivalent amounts
Thromboelastometry- rapid point-of-care assessment of coagulation
used to guide trauma resuscitation
Anatomical control of bleeding
10. PROMMTT study-2013-US
Prospective Observational multicentre major Trauma Study
n=1245
showed clear mortality benefit in 1st 24 hrs with blood product use in 1:1:1
ratios
11. PROPPR[RCT 2015]
680 severely injured pts
24- hour and 30-day mortality rates following trauma with severe bleeding
were not different when FFP, platelets and RBCs were transfused in a 1:1:1
or 1:1:2 ratio
both groups similar complications rates were reported
However, in the 1:1:1 ratio group the PROPPR investigators found a
reduced number of fatalities due to exsanguination
12. Massive transfusion protocol[MTP]
When to activate
1.Anticipated severe haemorrhage from history before patient arrival
2.Code Red : When USS not available or History from Ambulance Crew
Systolic blood pressure <90 hgmm
Unresponsive to one fluid bolus
Suspected or confirmed massive haemorrhage
3.ABC score [Assessment of blood consumption Score] – 2 or more points
●Penetrating mechanism of injury
●Positive FAST (Focused Assessment with Sonography in Trauma) examination
●SBP of 90 mmHg or less
●Heart rate of 120 beats per minute (bpm) or greater
13. MTP
Predefined and balanced transfusion products
Aim to prevent coagulopathy while increasing O2 carrying capacity
Data from war zones in Iraq and Afghanistan
replacement of >1 blood volume in 24 hours or >50% of blood volume in 4
hours
14. MTP-SCGH
4 units RBC
2 units FFP
1 adult therapeutic dose platelet
10 units cryoprecipitate if fibrinogen < 1.5 g/L
15. Antifibrinolytic agents- Tranexamic Acid
Recommended within first 3 hours of Trauma
CRASH2 Trial –RCT 2010 – Mortality benefit [Mortality 4.9% Vs 5.4%]
May increase bleeding if given in > 3 hours of trauma
1 g IV over 10 minutes and continue 1g/8 hours
No Thromboembolic events
16. Do not forget calcium
Calcium citrate – Lowers ionised Ca
Citrate overload from Blood products- inevitable consequence of receiving massive
transfusion
3mg in 1 unit PRBC
Usually rapidly cleared by liver – Impaired in trauma pt.
Normal iCa - 1.15-1.33 mmol/L
Below < 1.1 mmol/L
long QT, dysrhythmias
negative inotropy and vasoplegia, hypotension
hypocoagulability
Predicts Hospital Mortality
17. Calcium
Measure every 15-30 minutes while resuscitating
If iCa < 1mmol/L –replace with calcium chloride 1 g or 2 -3 g of calcium
gluconate
18. Parameters Values to aim for
Temperature >35 °C
Acid-base status ph >7.2, base excess <–6, lactate
<4 mmol/L
Ionised calcium (Ca) >1.1 mmol/L
Haemoglobin (Hb) This should not be used alone as
transfusion trigger; and, should be
interpreted in context with
hemodynamic status, organ &
tissue perfusion.
Platelet (Plt) >50 x 10
9
/L
PT/APTT <1.5x of normal
INR ≤ 1.5
Fibrinogen >1.0 g/L
20. Reversing Anticoagulants
A specific reversal agent/antidote
DDAVP
Drug removal from the circulation and/or gastrointestinal tract
Prothrombotic - Prothrombin complex concentrates
and other Blood products
21. FFP
Contains all coagulation factors
One unit is 200- 250 ml [ from I unit whole blood]
Dose 10-15 ml /Kg
Given Stat in haemorrhage
Stored at or below -25c
Thawed in 10-30 minutes
Expected to increase CFs by 2.5% to 10% per unit
If PT/APTT > 1.5 times the normal needs 2-8 units
22. Cryoprecipitate
Contains –Fibrinogen, Factors Viii,Xiii,vWF
Fibrinogen is the 1st CF to reach critical low levels
I unit is 10-20 ml
Comes in premade pools [ 1 to 5 units in one pool]
Dose 5- 10 units [ 50-200 ml]- may be 5 units / 5 kg BW in massive Trauma
haemorrhage
Stored at -25c or below . Thawed in 10-30 minutes
24. Direct Reversal of Anticoagulants
Dabigatran - Idarucizumab [2.5 g/50 mL (50 mL): $2100.00]
- 2.5 g IV x 2 :15 minutes apart – repeat once
- Haemodialysis
-PCC not recommended –used if antidote unavailable
-FFP and other blood products can be given as a Part of
MTP
Warfarin - Vit K 5-10 mg IV [ takes 6-12 hours]
-PCC [ recommended 4 factors with factor Vll]
- FFP with 3 Factor concentrate
25. direct factor Xa inhibitors - No antidote
- Can not be dialysed
- PCC and FFP
Reversal agents Under Development
Andexanet alfa – For Xa inhibitors and LMWH reversal
Ciraparantag- For Xa inhibitors, Direct Thrombin Inhibitors and LMWH
26. Prothrombinex – 3 factor combination
provision of factors II, IX and X
Available in Australia-Prothrombinex -VF
Dosing is based on units of factor IX activity
Correct INR with in 30 minutes
30- 50 IU/ kg given IV
27. Protamine
Reversal of Heparin
Heparin inactivates Thrombin and Xa
1mg / 100 units of Heparin [ 25-50 mg IV ]
For Enoxaparin given within 8 hours 1 mg / 1mg
Given > 8 hours ago 0.5mg/1mg
SE -anaphylaxis in individuals who have previously been exposed to
protamine [ DM , Fish allergy]
28. rFVII concentrate
Off – label use in Traumatic Haemorrhage
Only approved for Haemophilia and Platelet functional disorder associated
bleeding
Available research – No mortality benefit
- May reduce amount of transfusions
- May increase Thromboembolic risk
shows significant potential and appears to be safe in young, previously healthy
individuals with traumatic haemorrhage
29. Desmopressin (DDAVP)
-Synthetic analogue of ADH
-Increase release of Factor Vlll and vWF from platelets and
endothelial cells
-Used mostly for intra-op microvascular bleeding in vWF deficiency or
suspected platelet dysfunction in uraemia
30.
31. Anatomical Control of bleeding
Internal bleeding – manage as appropriate –
OT -damage control surgery/ Angiographic embolization
Pelvic binder
Reduce and splint long bone fractures
Cross clamp aorta
IABP
External bleeding
Direct Pressure
Staples to scalp wounds
Tourniquet
Ligate vessels
Folly catheter
32. Damage controlled surgery
Aims
-Arrest bleeding
-Limit contamination
-Maintain blood floor to organs and extremities
-Continue resuscitation in ICU
-Delayed definitive surgical management once patient is stable
33.
34. What if TBI or SCI in the same patient?
Minimal Normotention [ 70-90 hgmm SBP . MAP 50-65 hgmm . Mentation ,
Radial pulse ]?
Controversial
Some resuscitates to above
Some recommend MAP 85-90 hgmm
Therefore should be individualised
Maintain haemostasis
Vasopressors may be needed in refractory Neurogenic shock once
haemorrhagic shock is excluded or treated to the best possible level
35. Monitor Progress on Haemostasis?
Time Critical assessments …
Clinical assessment and
HR , BP , Pulseoxymetry , GCS, UOP
ROTEM
Base excess, Lactate , iCa , Hb
36. Is it Really Working ?
Activation of Coagulation and inflammation of trauma study
Prospective cohort study – 2014 International Trauma Research Network
106 pts. receiving MTP- Trauma centres UK and Norway
ROTEM and Lactate measurements
Shows No improvement of lactate and showed worsening of Coagulopathy
But –
-High Ratios RBC:FFP:Platelets were not achieved until late in resuscitation
-Crystalloids were administered
-PROMMTT study 2013 n=1245 showed clear mortality benefit in 1st 24 hrs with 1:1:1
ratios
38. Shows limited abnormalities of initial phase of coagulation
Main use is monitoring Heparin, warfarin and haemophilia
Takes 40-45 minutes
Coagulation Profile….
39. ROTEM…
information within 5 minutes
Real-time measurements using whole blood
guide coagulation therapy according to actual needs
Reduced transfusion requirements
Reduced transfusion related adverse events
Improved outcomes
Used in various clinical settings – liver transplant, cardiac surgery, obstetrics &
trauma
High negative predictive value –If normal results -bleeding highly unlikely due
to significant coagulopathy
Provide information in overall haemostasis even one component is lacking –
Low platelets compensated by high Fibrinogen
Lacks data on effects of DOACs
44. Summary …
Early recognition and appropriate resuscitation
Varies according to individual and injuries
Involve all relevant specialities early-Early definitive Mx of haemorrhage
Damage control resuscitation
Use ROTEM/ continue to monitor – Clinical, BA, Lactate, Ca
Tranexamic acid < 3 hours
Modifications in-Head injury , Spinal injury
Complications of MT