Hemostatic Resuscitation

Transcription

1 Hemostatic Resuscitation 30 th David Miller Trauma Symposium Bill Beck, MD Assistant Professor of Surgery Trauma, Emergency General Surgery, Critical Care

2 Disclosures None Again. Mac user.

3 Why I Like Trauma?

4 Background Hemorrhage is responsible for >80% of trauma OR deaths and >50% of deaths in the first 24 hours after injury. Rapid identification of coagulation abnormalities appears critical to improving survival Most current transfusion protocols are not individualized

5 1980 s

6 1980 s

7 The best prehospital fluid is diesel fuel -Ken Mattox, MD

8 90 s/2000 s

9 Just Give Them Blood. 2-6 x increase SIRS 4 x increase in ICU Mortality 3.5 x increased odds ratio of infection

10 Defining the Massively Transfused > 20 units in 24 hours, or one circulating blood volume > 10 units in 24 hours (2010-Nunez)

11 Epidemiology MTP in 3-5% of civilian trauma patients 25% of patients needing MTP have evidence of coagulopathy This group consumes 75% of all blood products in trauma centers.

12 To improve survival, transfusion ratios were protocolized

13 PROPPR Evaluated ratio of 1:1:1 to 1:1:2 for Plasma:Platelets:PRBC 680 patients No mortality difference at 24 hours and 30 days Fewer deaths by exsanguination and more achieved hemostasis in 1:1:1 No differences in safety events, although 1:1:1 received more products

14 When to activate? Earlier activation is better (ABC) Usually no lab values back

15 Assessment of Blood Consumption for MTP Penetrating Mechanism ED Systolic BP < 90 ED HR > 120 FAST Get 1 point for each positive finding >2 Points correctly classified 85% of people needing MTP If negative, this does not mean the patient will not need blood, just unlikely to require massive transfusion

16 Variability Despite all evidence and multiple scoring systems, < 50% of all activations occurred in the ED.

17 Turns out, that s bad. 680 pts with MTP Patient arrival to call = 9 min ; 8 min to cooler arrival Every minute delay increased MORTALITY by 5%

18 What can I do? Establish MTP protocols Follow said protocols Keep blood products in the ED ACTIVATE PREHOSPITAL (ABC) 60% odds reduction in 30-day mortality when controlling for admission injury severity and physiology (thawed plasma)

19 Assessment of Blood Consumption for MTP Penetrating Mechanism ED Systolic BP < 90 ED HR > 120 FAST Get 1 point for each positive finding >2 Points correctly classified 85% of people needing MTP If negative, this does not mean the patient will not need blood, just unlikely to require massive transfusion

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21 Courtesy of Bryan Cotton

22 ROTEM Thromboelastometry - technology

23 PT, aptt Limitations PT/aPTT do not reflect fibrin polymerization, FXIIIa or fibrinolysis Thrombin generation PT, aptt Thrombin generation continues / building clot (with fibrinogen, platelets and FXIIIa) Thrombin generation needed to start clotting

24 N=1262 INR > 1.4 PTT > 35 gov/pubmed/

25 The graph information or TEMogram Time (in sec)) Amplitude in (mm) The greater the amplitude the firmer the clot The graph demonstrates the change in amplitude (clot firmness) over a time period

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27 TEG Phenotypes 180 patients 21% penetrating ISS > 15 10% with hyperfibrinolysis 60% of patients had fibrinolysis shutdown

28 Cause of death is different Fibrinolysis patients die from hemorrhage Shutdown patients more commonly die from organ failure

29 Hyperfibrinolysis 84 patients, 42 matched pairs 17% patients with hyperfibrinolysis Death Diamond 100 % specificity for death Consumed 4 x blood products

30 Hyperfibrinolysis Detection of Hyperfibrinolysis 118 patients, highest activation, LA County, ~ 10% with hyperfibrinolysis 62% of these patients dead at 6 hours Greater need for massive transfusion (3/4 with hyperfibrinolysis vs 1/10 without evidence of hyperfibrinolysis)

31 Can replace conventional coagulation tests in ER 1974 consecutive trauma patients in Houston Compared to conventional coagulation studies including fibrinogen Controlled for age, sex, MOI, base deficit, revised trauma score, and ISS all rteg values were predictors of 24 hour and 30 day mortality Only PTT was predictor from conventional tests rteg results delivered faster

32 The graph information or TEMogram CT = 0-2 mm The broken green lines provide a marker at 40mm for an easier visual estimation of amplitude The graph and TEMogram provides colors and other visual markers to aid in the rapid assessment of the developing clot.

33 The graph information or TEMogram CFT = 2 20 mm The broken green lines provide a marker at 40mm for an easier visual estimation of amplitude The graph and TEMogram provides colors and other visual markers to aid in the rapid assessment of the developing clot. PR v01

34 The graph information or TEMogram Firm & Stable Unstable (early Lysis) Relatively Weak

35 CT CFT α PLASMA ML TXA A10 A20 MCF PLATELETS FIBTEM Cryoprecipitate

36 ROTEM Interpretation If this is prolonged, give FFP Measured Parameter CT (sec) Clinical Significance Clot Initiation IN = EX = CT Measured in (sec) - Reflects the patients ability to generate thrombin resulting in the onset of clot formation

37 ROTEM Interpretation If this is low, need platelets (fibtem normal) and cryo (fibtem abnormal) Measured Parameter CT (sec) Clinical Significance Clot Initiation A10 (mm) Clot Firmness A10 = Amplitude (A10, A20 & MCF) Measured in (mm) - Reflects the firmness and stability of a clot i.e. interaction of platelets, fibrin and FXIIIa.

38 ROTEM Interpretation If ML > 3% then need TXA Measured Parameter CT (sec) Clinical Significance Clot Initiation A10 (mm) Clot Firmness ML (%) Clot Lysis Maximum Lysis ML Measured in (%) - Reflects the degree of clot lysis ML = > 15%*

39 Clot Retraction not Lysis

40 Platelets contribute 80% of overall clot strength; remaining 20% is contributed by the fibrin network. 40

41 The important takeaway information Learn to recognize what Normal looks like Keep it simple to start: CT/CFT Thrombin Generation PLASMA (PCC) A10 Amplitude / Clot Firmness PLT/CRYO ML Clot Lysis PRESCRIPTION (TXA) PR v01

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46 Questions? Bill