Damage Control Resuscitation. VGH Trauma Rounds 2018 Harvey Hawes

Transcription

1 Damage Control Resuscitation VGH Trauma Rounds 2018 Harvey Hawes

2 Example Case 25yo F in motor vehicle collision at high speed Picked up at scene by Helicopter EMS unit Initial vital signs: HR 134 BP 88/42 GCS 10/15 What is the primary problem here?

3 Example Case A. What would you instruct paramedics to do next? a. Nothing, just transport patient rapidly to hospital b. Give 2L saline IV wide-open c. Give 2 units packed red blood cells and 2 units of FFP

4 The old days Crystalloid resuscitation Preload directed or Supranormal resuscitation came in the 1990s Delivery of Oxygen Index (DO2I) was calculated via a Swan-Ganz Target of >600 ml/min m2 Many litres of crystalloid given to achieve this Blood reserved for refractory bleeding Shoemaker, et al. Chest

5 Crystalloid Era Typical post-operative scenarios were seen

6 Debunked

7 but we had it right 80 years earlier

8 The old old days

9 The old old days Charles Best Norman Bethune

10 How did we get it wrong? Trauma systems were evolving War surgeons were returning to inner city war zones Intensive care units being developed Mortality Prehospital became a thing Time Mortality rates were falling for many reasons

11 How did we get it wrong? Shires believed that the interstitium needed to be resuscitated first, before giving blood products This is the paper where the ATLS 2L of saline come from Different in ALTS 10th Ed

12 How did we get it wrong? Fractionation of whole blood Components marketed as allowing clinical flexibility Better storage of some products Increased revenue of mostly private blood banks

13 This is not blood

14 Houston:

15 Four Studies

16 Four Studies

17 Four Studies

18 Four Studies

19 Bonus Study Underrated study, but most important to Holcomb...

20 Damage Control Resuscitation Benefits Improved survival of the highest ISS patients Less blood product use (how?) Quicker normalization of coagulopathy Less wasted blood products Less open abdomens

21 Physiologic Benefits Many theories now being developed to explain findings Endotheliopathy - inflammatory damage to microvessels Repaired by FFP, cryo and dried plasma, whole blood Worsened by crystalloid Supporting and maintaining initial clot TXA, fibrinogen

22 Risks of Crystalloids Crystalloid resuscitation: Volume of crystalloids are linearly related to mortality Is acidotic Dilutes clotting factors Damages vessel endothelium Contributes to CRALI (Cotton s retort to TRALI)

23 back to our case

24 Example Case 25yo M in motor vehicle collision at high speed Picked up at scene by Helicopter EMS unit Initial vital signs: HR 134 BP 88/42 GCS 10/15

25 Example Case During Helicopter transport FAST Ultrasound positive for blood in abdomen 2 units of PRBCs and FFP transfused Hospital contacted and Massive Transfusion Protocol activated

26 Example Case Patient arrives to hospital Vital Signs: HR 115 BP 108/55 What do you do next?

27 Example Case ATLS primary and secondary survey completed Chest tube placed (500cc blood out) Chest X-ray, Pelvis X-ray done, FAST + Vital signs: HR 118 BP 90/50 14 minutes has elapsed since arrival to hospital

28 Example Case This patient met our criteria for massive transfusion Trauma blood bank at bedside opened on arrival Continued with Platelets, FFP and PRBCs Patient stable enough for CT scan in trauma bay

29 Example Case

30 Example Case Left hemothorax resolved with chest drain Blunt liver injury (Grade III) Right renal injury (Grade II) Juxtarenal IVC injury with large hematoma

31 Example Case Vital Signs: HR 108 BP 117/78 Total transfusion now at 5 units PRBC, 5 units FFP and 5 units of Platelets Total time elapsed 40 minutes What would you do next?

32 Example Case Patient transferred to STICU for observation (!?!?!?) TEGs and VBG normalized within 3 hours Did not require laparotomy IVC filter placed above IVC injury Eventually discharged home on oral anticoagulation Filter taken out day 30

33 Example Case - Points This is a case of DCR providing Control of Bleeding without intervention Early (pre-hospital) detection of hemorrhagic shock Damage Control Resuscitation 1:1:1 ratio of blood products used 660cc of crystalloid used from field to STICU Restoration of coagulation system No laparotomy needed

34 Principles How do we do it?

35 Principles 1. Rapidly identify need and activate protocol 2. Permissive hypotension 3. Resuscitate blood loss with whole blood 4. Do not delay hemorrhage control

36 Principles 1. Rapidly identify need and activate protocol Good understanding of causes of shock in trauma Hemorrhagic, hemorrhagic, hemorrhagic Obstructive (Tension PTX, Tamponade) Distributive (Brain or spine) HR 70, SBP 70 Need scoring system ABC score, Shock Index, etc

37 Principles 1. Rapidly identify need and activate protocol ABC score (Assessment of Blood Consumption --aka Angry Bryan Cotton ) Two of: SBP < 90mmHg HR > 120bpm Penetrating Trauma Positive FAST exam

38 Principles 1. Rapidly identify need and activate protocol Don t wait for blood work! VBG look at Base Deficit to monitor resuscitation Type and Screen Don t wait for it. Give Universal Donor INR/PTT, Hgb only useful if medical comorbidities Coumadin use Normal INR/PTT means little about clot formation and strength

39 Principles 2. Permissive hypotension Accept systolic BP around 90mmHg Except for brain or spine injury Don t pop the clot Don t waste products

40 Principles 3. Resuscitate blood loss with blood NO CRYSTALLOID! Kills bleeding patients Furthers endothelial damage Dilutes clotting factors Use it only after bleeding is stopped Need to limit use in the field The sweet spot is likely ~1L prior to hemorrhage control 100 ml

41 Principles 3. Resuscitate blood loss with blood What to give and when? How to give it? When to stop?

42 Principles 3. Resuscitate blood loss with blood What to give and when? Resuscitate coagulation system Replenish coagulation factors Reverse acidosis Replenish platelets early Early FFP and Platelets saves lives

43 Principles 3. Resuscitate blood loss with blood What to give and when? Resuscitate O2 carrying capacity Give RBCs as needed Don t pour Red Cells out a hole

44 Principles 3. Resuscitate blood loss with blood What to give and when? 1:1:1 Simple protocol to use while bleeding Protocol stops when surgical control of bleeding achieved

45 NOTE - (FFP:Plts:RBC) The ratio is roughly recreates whole blood 6 units FFP (sometimes come as doubles ) 6 units Plts (pooled suspended in plasma) The fastest available product! 6 units PRBC Think of them as 6:6:6 in the box Anemic, cold, acidotic, old blood

46 Principles 3. Resuscitate blood loss with blood What to give and when? Adjuncts Cryoprecipitate? (or Fibrinogen Concentrate) Yes, but what form and when? Tranexamic acid? Yes, but in the first 3 hours Octaplex/PCCs? Maybe in the near future Factor VIIa? Not anymore

47 Principles 3. Resuscitate blood loss with blood How to give it? Warm! Fast! Level 1 rapid infuser That means BIG IV s, Humeral IO, or Cordis An 18ga is NOT a big IV!

48 Principles 3. Resuscitate blood loss with blood

49 Principles 3. Resuscitate blood loss with blood When to stop? When control of bleeding achieved No cardiac activity Keep real-time count! FFP PLTs PRBC

50 Principles A satisfying resuscitation This is why flow rates matter Each bag is ~400ml

51 Principles but that s just straight 1:1:1 Can we have more guidance? INR/PTT? - To slow, not granular enough ROTEM / TEG - Rapid, multifactorial, repeatable, cheap Can tailor products to actual data Fibrinogen, Platelets, Plasma, TXA

52 Expanded role of DCR? Sepsis resuscitation DIC resuscitation* Amniotic fluid embolus* GI bleed* PPH* Evidence starting to come out for some of these indications

53 Remote DCR What if you in a rural setting, or the field? 2 units of blood in many Level V hospitals Long transport times Do you give crystalloid? How much? When? 2018 THOR consensus statement: Prolonged SBP < 100mmHg detrimental Rapid Transport and controlling the bleeding important (tourniquet, REBOA)

54 Cold-stored Whole Blood (CWB) Why do we have to use fractionated blood? Antigenicity? Storage? Platelet function? Wastage? Nope. It s coming. Surgeons win! This IS Blood!

55 Questions?