Damage Control Resuscitation

Transcription

1 Damage Control Resuscitation H M Cassimjee Critical Care Specialist Department of Critical Care & Level 1 Trauma Unit Inkosi Albert Luthuli Central Hospital

2 Damage Control Resuscitation only for DAMAGED PATIENTS

3 Damage Control Resuscitation Hypotensive Resuscitation Haemostatic Resuscitation + Aggressive Warming Damage Control Surgery

4 Epidemiology David S. Kauvar, MD, Rolf Lefering, PhD, and Charles E. Wade, PhD. Impact of Hemorrhage on Trauma Outcome: An Overview of Epidemiology, Clinical Presentations, and Therapeutic Considerations. J Trauma. 2006;60:S3 S11.

5 Epidemiology Exanguination : commonest cause of DOA David S. Kauvar, MD, Rolf Lefering, PhD, and Charles E. Wade, PhD. Impact of Hemorrhage on Trauma Outcome: An Overview of Epidemiology, Clinical Presentations, and Therapeutic Considerations. J Trauma. 2006;60:S3 S11.

6 31% Mortality for Direct Admissions 2 / 3 DEAD WITHIN 12 HRS ISS 41 S Afr Med J 2011;101:

7 Epidemiology Sauaia, Angela MD; Moore, Frederick A. MD; Moore, Ernest E. MD et al. Epidemiology of Trauma Deaths: A Reassessment. J Trauma :38(2), February 1995, pp

8 Epidemiology Heckbert, S R Outcome after Hemorrhagic Shock in Trauma Patients. J Trauma 45(3) 1998, pp

9 Epidemiology 8 % of Trauma pts Transfused 3 % of all Trauma pts ± 75% of BLOOD USE John J. Como, Richard P. Dutton, Thomas M. Scalea. Blood transfusion rates in the care of acute trauma. TRANSFUSION 2004;44:

10 Uncontrolled coagulopathic hemorrhage is now the major cause of potentially preventable death following trauma. Hess J R. Editorial. Damage control resuscitation: the need for specific blood products to treat the coagulopathy of trauma. Volume 46, May 2006 TRANSFUSION 685

11 Hemorrhage, which produces such terror in the bystanders.... Should never unnerve the surgeon, who requires all of his self possession... To cope successfully with this ebbing away of life. J.J. Chisolm, Surgeon General, Confederate States of America Chisolm JJ: A Manual of Military Surgery, for the Use of Surgeons in the Confederate States Army; with an Appendix of the Ruies and Regulations of the Medical Department of the Confederate States, p 127. Richmond. VA, West & Johnson

12 Ann. Surg. VOl. 197(5):

13 The innovation of Damage Control : Once coagulopathy noted: Operation immediately aborted Abdominal tamponade effected Closure under tension Reexploration when pts blood adequately clotted Ann. Surg. VOl. 197(5):

14 93% MORTALITY RATE 35% Ann. Surg. VOl. 197(5):

15 Ann. Surg. VOl. 197(5):

16 Predicting Mortality The Bloody vicious cycle : Injurity severity score > 25 ph < systolic blood pressure < 70 Core temperature < 34 c When all 3 present: incidence of coagulopathy = 98% Cosgriff N, Moore E, Sauaia A et al. Predicting Life-threathening Coagulopathy in the Massively transfused Trauma Patient: Hypothermia and Acidosis Revisited. J Trauma 42(5)

17 The Deadly Triad hypothermia acidosis coagulopathy

18 Bloody Vicious Cycle Bleeding Resuscitation Coagulopathy Acidosis Hypothermia

19 Bloody Vicious Cycle Bleeding Depletion Resuscitation Coagulopathy Acidosis Hypothermia

20 Bloody Vicious Cycle Bleeding Resuscitation Coagulopathy Depletion Dilution Acidosis Hypothermia

21 Bloody Vicious Cycle Bleeding Resuscitation Coagulopathy Depletion Dilution Dysfunction Acidosis Hypothermia

22 Bleeding Resuscitation Coagulopathy Depletion Dilution Dysfunction Acidosis Hypothermia

23 Bleeding Resuscitation Coagulopathy Depletion Dilution Dysfunction Acidosis Hypothermia

24 J Trauma. 2003;54:

25 24.4% coagulopathy on admission Base Deficit > 6 J Trauma. 2003;54:

26 John R. Hess, Allison L. Lindell, Lynn G. Stansbury, Richard P. Dutton, and Thomas M. Scalea. TRANSFUSION 2009;49:34-39.

27 Coagulopathy of Trauma SHOCK / HYPOPERFUSION Thrombomodulin Activation of Protein C

28 Coagulopathy of Trauma endothelium TM APC THROMBIN tpa tpa tpa tpa tpa tpa tpa tpa tpa tpa tpa tpa PAI-1 PA I-1

29 Fibrinolysis TRAUMA Coagulation

30 General consensus: Early use of RBC + plasma + platelets offers best chance of limiting coagulopathy

31 1 : 1 : 1

32 Dutton RP. Shock Management. Trauma Anaesthesia. Ed Smith CE, Como JJ. Cambridge University press

33 J Trauma. 2007;63:

34 Time to death 2 Hrs Time to Death 4 Hrs 38 Hrs Haemorrhage Mortality Rates 92.5% 78 % 37 % J Trauma. 2007;63:

35 Studies recommending higher plasma : RBC ratios Stahel PF et al. Transfusion strategies in postinjury coagulopathy. Curr Opin Anaesthesiol. 2009;22:

36 J Trauma. 2009;66:

37 J Trauma. 2010;69: 46 52

38 J Trauma. 2010;69: 46 52

39 24 hrs Heckbert, S R Outcome after Hemorrhagic Shock in Trauma Patients. J Trauma 45(3) 1998, pp

40 Avoid fluids that don t clot or carry oxygen!! R Dutton EMCRIT webcast

41 J Trauma. 2002;52: J Trauma. 2011;70:

42 Hypotensive Resuscitation With judicious fluid administration not vasoactive agent use Difficult to keep blood pressure at hypotensive threshold Hypotensive pts did no worse Hypotensive pts bled less

43 Trauma Outcomes Avoid fluids that don ART Or SYSTEM?

44 > 50u BLOOD in 48hrs Cinat, M. E. et al. Arch Surg 1999;134:

45 REPLICATE THIS!! NOT AN EXERCISE IN FUTILITY!! 69% survival! P. Hakala et al. Injury, Int. J. Care Injured 30 (1999) 619±622

46 NOT AN EXERCISE IN FUTILITY!! HIGHEST PRBC TRANSFUSION DOCUMENTED IN A SURVIVOR??

47 NOT AN EXERCISE IN FUTILITY!! HIGHEST PRBC TRANSFUSION DOCUMENTED IN A SURVIVOR?? 167 UNITS > 150 UNITS IN 1 ST 15 HOURS

48 Damage Control Resuscitation The Damage that really matters?

49 The enemy within DAMAGED PATIENTS DAMPs Damage Associated Molecular Patterns

50 Vargas-Parada, L. (2010) Mitochondria and the Immune Response. Nature Education 3(9):15

51 FASEB J. 17, (2003) Time also matters

52 Damage Control Resuscitation Rapid identification: smashed / damaged ABG & INR on admission ROTEM / TEG

53 Damage Control Resuscitation Rapid identification Haemostatic resuscitation: Hypotensive resuscitation Aggressive re-warming every drop of fluid through an in-line warmer 1:1:1 if significant blood transfusion considered

54 Damage Control Resuscitation Rapid identification Haemostatic resuscitation Damage Control Surgery: Theatre ASAP: minutes

55 BLOOD IS THICKER THAN WATER

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57 Trends in Immunology April 2011, Vol. 32, No. 4