3/16/15. Management of the Bleeding Trauma Patient: Concepts in Damage Control Resuscitation. Obligatory Traumatologist Slide

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1 Management of the Bleeding Trauma Patient: Concepts in Damage Control Resuscitation Courtney Sommer, MD MPH Duke Trauma Symposium March 12, 2015 Obligatory Traumatologist Slide In 2010 trauma was leading cause of death for Americans under 47 years old trauma leading cause of death for Americans 0-56 years Remains the leading cause of years of life lost Trauma 30% Cancer 16% Heart Disease 12% Rhee et al. Ann of Surg 2014 nationaltraumainstitute.org Trauma Deaths by Age Rhee et al. Ann of Surg

2 What Do People Die of? 4 What Do People Die of? Hemorrhage 35% pre-hospital deaths 40% deaths within first 24 hours Leading cause of preventable death Morbidity and mortality strongly associated with bleeding and need for transfusion Kauvea et al. J Trauma Damage Control Resuscitation Early hemorrhage control OR IR Permissive hypotension Minimize crystalloid (dilution) Target early coagulopathy 6 2

3 Damage Control Surgery Not a new concept Ugly Necessary evil in order to restore hemodynamics in the ICU Rotondo et al. J Trauma Damage Control Surgery 8 Endovascular Control of Hemorrhage Spleen Liver Kidney Pelvis 9 3

4 Endovascular Control of Hemorrhage 10 Endovascular Control of Hemorrhage 11 Endovascular Control of Hemorrhage 12 4

5 Endovascular Control of Hemorrhage 13 Endovascular Control of Hemorrhage 14 Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) 15 5

6 Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) 16 Summary Early Hemorrhage Control Recognize injury pattern Determine possible control methods Mobilize resources needed Move somewhere to control hemorrhage OR IR 17 Permissive Hypotension Low volume resuscitation Don t want to pop the clot Injection of a fluid that will increase blood pressure has dangers in itself if the pressure is raised before the surgeon is ready to check any bleeding that might take place, blood that is sorely needed may be lost -Walter B. Cannon, 1918 Cannon et al. JAMA

7 Permissive Hypotension Shock is bad Failure to clear lactate or base deficit leads to Acute lung injury Increased infectious complications Increased mortality In most people we want to correct shock Actively bleeding patients goal directed therapy is NOT possible Claridge et al. J Trauma Data for Permissive Hypotension 598 Patients with penetrating trauma Immediate! fluid before OR Delayed! Fluid in/after OR 20 Data for Permissive Hypotension Data on arrival Bickell et al. NEJM

8 Data for Permissive Hypotension Data after resuscitation Bickell et al. NEJM Data for Permissive Hypotension Pre-hospital and ED fluid volume 2500ml vs 375ml No difference in OR fluid volumes c Bickell et al. NEJM Data for Permissive Hypotension 24 8

9 Data for Permissive Hypotension No difference in mortality Could not achieve resuscitation to SBP 70 Patients will find a MAP for their current physiology Similar to Mattox study Cyclic hyper resuscitation Dutton et al. J Trauma Cyclic Hyper Resuscitation Dutton et al. J Trauma Permissive Hypotension with TBI? Few studies in humans TBI patients excluded Several animal models suggest that low volume resuscitation may still be appropriate Crystalloid has potential to increase ICP more than MAP Cerebral autoregulation may be sufficient to tolerate transient lower BPs Lower MAP/SBP must be tolerated from neurologic standpoint until hemorrhage is controlled Talmore et al. Anesth & Analg 1999 Bourguignon et al. Arch Surg

10 Ongoing Trial Randomized at entry into OR to MAP 50 vs 65 Low MAP group: Received less blood and fluids Less postop coagulopathy Improved survival curve Morrison et al. J Trauma Summary Permissive Hypotension With ACTIVE hemorrhage: Small volume fluid boluses (~250) Titrate to radial pulse or MAP ~50 Debatable in head injured population Limit hypotension to mins Use blood/ffp Move to somewhere to obtain hemorrhage control 29 Target Coagulopathy Hess et al. J Trauma

11 Target Coagulopathy 31 Acute Traumatic Coagulopathy Brohi et all. J Trauma Acute Traumatic Coagulopathy 33 11

12 Coagulopathy Predicts Death Abnormal PT Macleod et al. J Trauma Resuscitation Protocols Borgman et al. J Trauma Survivorship Bias Patients who die early never have a chance to receive plasma Studies that exclude early deaths miss precisely the patients who might benefit from plasma 80% hemorrhagic deaths occur in first 6 hours Transfusion ratios are constantly changing, especially in first 6 hours Ho et al. Anesth 2012 Holcomb et al. JAMA Surg

13 What Are Trauma Centers Doing? 37 PROMMTT Study 905 patients at 10 level I trauma centers Patients who received > 3 units PRBCs in first 24 hours In hospital mortality Findings: Ratios not constant over 24hrs Early mortality (6hrs) decreased with ratios closer to 1:1 After 24 hours transfusion ratios not associated with mortality Holcomb et al. JAMA Surg 2013 Del Junco et al. J Trauma PROPPR Trial Cotton et al. JAMA

14 Target Coagulopathy Resuscitating with blood products early in bleeding patients improves outcomes Other ways to treat coagulopathy? Tranexamic acid (TXA) Concentrated factors PCCs Cryoprecipitate Fibrinogen Thromboelastography guided 40 Tranexamic Acid 41 CRASH-2 Trial Lancet

15 CRASH-2 Trial >20,000 patients Trauma patients with or at risk of bleeding Treated within 8 hours 1 gram bolus followed by 1gm over 8 hrs All cause mortality reduction of 1.5% Only death from bleeding affected Benefit most apparent in severe shock group and when given within 1 hr 43 CRASH-2 Limitations Napolitano et al. J Trauma MATTERs trials Retrospective analysis of TXA (and cryo) use in US military population Both trials demonstrated lower mortality in those treated with TXA (+/- cryo) compared to those not treated Limitations: Retrospective Not standardized indications or doses No data regarding timing Incorporated into guidelines for combat casualty care 45 15

16 Pre-hospital TXA (PATCH Study) 46 STAAMP Trial 47 Prothrombin Complex Concentrate 3 factor and 4 factor products Inactivated Factor II, (VII), IX, X 25x higher factor content than FFP 1 dose equivalent to 8-16u FFP Dramatically less volume than FFP Contain no fibrinogen FDA approved in hemophilia and life threatening bleeding in patients on VKAs 48 16

17 Cryoprecipitate PROMMTT trial evaluated use of cryo in trauma Use varied from 7-82% among trauma centers No association with mortality Even in death from hemorrhage (<6hrs) most did not receive cryo (28% received) Hyperfibrinolysis well documented in ATC Hyperfibrinolysis associated with high mortality Enthusiasm for early use of cryo and/or fibrinogen concentrates Levrat et al. B J Anesth 2008 Pommerening et al. JACS CRYOSTAT Trial 50 Guided Targeting of Coagulopathy TEG and ROTEM Clot formation, propagation, stabilization, and dissolution Guide resuscitation Point of care test 51 17

18 Thromboelastography McCoy et al. Clin Lab Med Thromboelastography in Trauma Da Luz et al. Crit Care Summary Target Coagulopathy Aim for 1:1 (you probably won t achieve it) Consider plasma first Consider TXA if significant bleeding suspected Give TXA if in hem shock and < 3hrs from injury Consider PCCs in patients on VKAs with life threatening bleeding Administer PCC if sig ICH with VKAs POC thromboelastography has potential to guide specific targeted resuscitation 54 18

19 Damage Control Resuscitation Early hemorrhage control OR IR Permissive hypotension Minimize crystalloid (dilution) Target early coagulopathy 55 Questions? 56 19