Management of the Trauma Patient. Elizabeth R Benjamin MD PhD Trauma and Surgical Critical Care Critical Care Symposium April 20, 2015
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1 Management of the Trauma Patient Elizabeth R Benjamin MD PhD Trauma and Surgical Critical Care Critical Care Symposium April 20, 2015
2 Saturday Night 25 yo M s/p high speed MVC Hypotensive in the ED, altered OR for laparotomy & thoracotomy Injuries: Unknown head injury Hemothorax with lung resection Bowel injury with resection Pelvic fracture Near amputation lower leg
3 Arrival to the ICU Per operating surgeon: 25 yom, high speed MVC, nearly died in the ED. I took him to the operating, did an exlap, thoracotomy, controlled the bleeding. I gave a bunch of blood. He should do fine, not much else for you to do just keep him alive.
4 Arrival to the ICU Translation: Multi-system trauma Massive resuscitation Possible ongoing bleeding Unknown volume status Incomplete injury workup Long night ahead
5 What can I do in the ICU?
6 Trauma Care in the ICU 1. Hemorrhage Control 2. Coagulopathy of Trauma 3. Damage Control Resuscitation 4. Balanced Transfusion
7 #1 Cause of Death in Trauma = Hemorrhage
8 Hemorrhagic Shock Physiologic Response Tachycardia Vasoconstriction Narrowed pulse pressure Hypotension
9 Hemorrhagic Shock Class Blood Loss Response I <15% HR<100 II 15-30% HR>100, Orthostatic III 30-40% HR>120, Hypotension, Confusion IV >40% HR>140, Profound Hypotension, Lethargy
10 Uncontrolled Hemorrhage Coagulopathy
11 COAGULOPATHY OF TRAUMA ü 3-4x Mortality if Coagulopathic
12 Acidosis Hemodilution Hypothermia COAGULOPATHY
13 Coagulopathy of Trauma Transfusion requirement ICU length of stay Hospital length of stay Mechanical ventilation days Incidence of MODS
14 Rule #1 Stop the Bleeding!
15 Arrival to the ICU Temporary abdominal closure 200cc in the wound vac canister since transport Near amputation dressings soaked with blood Pelvic fracture no intervention
16 Compressible Hemorrhage When the patient arrives: ü Check all pulses ü Check all dressings ü Direct pressure when needed
17 Hemorrhage Control External Compression 1. Tourniquets 2. Binders
18 Extremity Trauma Tourniquets/Direct Compression
19 Trauma care in the ICU Tourniquets
20 Tourniquets
21 Pelvic Trauma Potentially Compressible!
22 Who Bleeds? Pubic symphysis diastasis > 2.5 cm Sacroiliac joint disruption Persistent hemodynamic instability Active extravasation on CT scan Advanced age + major pelvic fracture
23 Pelvic Binder No Binder Binder
24 Pelvic Binder: How to? Position over the greater trochanters
25 Pelvic Binder: Why? Goals 1. Decrease pelvic volume 2. Hemorrhage control 3. Stabilize fracture
26 Iliac Wing Fractures
27 Rule #2 If you can t stop it from the outside, try from the inside!
28 Hemorrhage Control Pharmacologic Agents 1. Tranexamic Acid 2. Prothrombin Complex Concentrate
29 Tranexamic Acid Anti-fibrinolytic Inhibits plasminogen to plasmin Who should get it? When should I give it?
30 20,211 patients, 40 countries Broad inclusion criteria ~ 50% received blood transfusion Does TXA influence outcome?
31 CRASH-2 ü Decreased Mortality 14.5% vs 16.0% ü Less Mortality from Hemorrhage 4.9% vs 5.7% ü Mortality benefit at < 3hrs
32 Arch Surg, patients total, Military 293 patients received TXA All patients received transfusion
33 MATTERs Patients receiving TXA had: Improved coagulopathy Improved survival Most apparent in MTP
34 Bottom Line: TXA Anti-fibrinolytic May decrease transfusion requirement May decrease mortality Low side effect profile Remember to give early!
35 Surgeon s Addendum One hour later By the way, I think the ED nurse said he was taking warfarin at home for a DVT
36 Rule #3 Reverse Coagulopathy!
37 Special Considerations The Anti-coagulated Trauma Patient
38 Anti-Coagulation in Trauma Mortality Morbidity
39 Everyone is doing it! Atrial Fibrillation Stroke Myocardial Infarction DVT/PE Heart Disease Valve Disease CAD PVD Arthritis
40 Aspirin 19.3% adults (43 mil) 48.5% adults > 65 Agency for Healthcare Research and Quality 2005
41 Warfarin 4.0% trauma patients 12.8% trauma patients > 65yrs Warfarin + Trauma = Increased Mortality
42 Warfarin Vitamin K antagonist (VKA) Factor II, VII, IX, X How can we reverse?
43 Warfarin Reversal 1. Vitamin K 2. Fresh Frozen Plasma (FFP) 3. Prothrombin Complex Concentrate
44 Vitamin K Dosing IV: 5-10 mg Anaphylaxis: 3 in 10,000* Onset of action IV 6-8hrs
45 Fresh Frozen Plasma ü Contains coagulation factors ü Approximately 250cc/unit ü Initial dosing: cc/kg ü Onset: immediate ü Duration: 6hrs
46 FFP: Concerns? ü ABO typing ü Thawing prior to administration ü Large volume load ü Time for infusion ü Repeat INR checks to titrate dose ü Potential viral transmission
47 Prothrombin Complex Concentrate PCC Clotting Factor Concentrate
48 What is it? ü 25x concentration ü Lyophylized powder ü Small volume ü Virus inactivated ü No ABO type required ü Immediate Onset
49 What is in it? 4 Factor PCC II VII IX X Protein C & S Antithrombin III Heparin
50 When to give it? FDA Approval indicated for the urgent reversal of VKA therapy in adult patients with acute major bleeding
51 2012 American College of Chest Physicians: Evidenced- Based Management of Anticoagulant Therapy For patients with VKA- associated major bleeding, we suggest rapid reversal of anticoagulation with four- factor prothrombin complex concentrate rather than with plasma
52 How much to give? Pre-treatment INR Dose 4F PCC Units/Kg 2 - <4 4-6 > Max Dose Not to exceed 2500 Not to exceed 3500 Not to exceed 5000 Dosing based on units Factor IX/kg body weight
53 4F-PCC n=103 FFP n= Mean Infusion Volume 99.4 ml ml Duration Administration 17 min 148 min
54 Advantages: 4F PCC ü Easy Accessibility ü Low Volume Administration ü Rapid Infusion ü Rapid Onset of Action ü Effective Hemostasis
55 Saturday Night Ongoing hemorrhage controlled Now what?
56 What principles guide trauma patient resuscitation? Reversal of coagulopathy Balanced resuscitation
57 Acidosis Hemodilution Hypothermia COAGULOPATHY
58 Damage Control Resuscitation 1. Limited crystalloid resuscitation 2. Early blood products plasma transfusion
59 Aggressive Fluid Resuscitation Decreased survival Increased coagulopathy Increased ARDS Abdominal compartment syndrome Increased trauma related SIRS
60 2013 Crystalloid = Morbidity ü SSI ü UTI ü Bacteremia ü Sepsis ü ARDS ü ARF
61 IVF Resuscitation Limit crystalloid infusion
62 Rule #4 Don t Miss Abdominal Compartment Syndrome!
63 Abdominal Compartment Syndrome High intra-abdominal pressure Strangulation of abdominal contents
64 Abdominal Compartment Syndrome Signs/Symptoms Increased abdominal distention Decreased urine output Increased peak airway pressures Hypotension Increased bladder pressures
65 Abdominal Compartment Syndrome Treatment Diuresis Sedation/Paralysis Decompression
66 Damage Control Resuscitation 1. Limited crystalloid resuscitation 2. Early blood products plasma transfusion
67 Balanced Resuscitation Early Product Administration
68 Blood Transfusion PRBC:FFP ratios Historical/Military: Whole blood Current Trend: Component therapy PRBC:FFP ratios
69 Does PRBC:FFP influence outcome?
70 Does FFP:PRBC influence outcome? Increased FFP:PRBC ü Decreased Mortality ü Decreased Mortality due to Hemorrhage ü Independent predictor of survival
71 Does FFP:PRBC influence outcome? ü Increased FFP = Decreased Mortality 41% vs 62% mortality ü Independent predictor of survival
72 Transfusion Goals How much FFP is enough?
73 PROPPR Pragmatic Randomized Optimal Platelets and Plasma Ratios 1:1:1 vs 1:1:2
74 PROPPR Pragmatic Randomized Optimal Platelets and Plasma Ratios ü No difference in mortality ü No safety difference 1:1:1 ü Earlier hemostasis ü Lower mortality due to exsanguination
75 Transfusion Goals Why don t we give FFP to everyone?
76 Patients with < 10u PRBC in 12hrs FFP transfusion increased: ü ARDS ü MSOF ü PNA ü Sepsis No survival benefit
77 Transfusion Goals 1. In Massive Transfusion, higher FFP ratios likely beneficial 2. FFP has a physiologic price Ø Reserve use for massive transfusion
78 Rules #5 and 6 Give blood early Balance resuscitation
79 Sunday Morning Dressings dry Hgb stable INR 1.2 HR 95, BP 100/60 UO 30cc/hr next patient rolling in
80 Summary Identify ongoing hemorrhage External compression Pharmacologic agents Reversal of coagulopathy Minimize crystalloid infusion Balanced resuscitation
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