Surgical Resuscitation Management in Poly-Trauma Patients
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1 Surgical Resuscitation Management in Poly-Trauma Patients Andrew Bernard, MD FACS Paul Kearney MD Chair of Trauma Surgery Associate Professor Medical Director of Trauma and Acute Care Surgery UK Healthcare and UK College of Medicine Lexington 0 Presenter Disclosure Information Andrew Bernard, MD Surgical Resuscitation Management in Poly-Trauma Patients FINANCIAL DISCLOSURE: No relevant financial relationship exists 1 1
2 2
3 Objectives 1. Synthesize evolving strategies in resuscitation 2. Compare available resuscitation fluids for trauma patients 3. Describe high ratio resuscitation and its evidence base 4 5 3
4 Damage Control Resuscitation (DCR) 1. Permissive hypotension 2. Haemostatic transfusion/resuscitation (FFP, PLT, PRBC, TXA) 3. Damage control surgery or angiography 4. Restore organ perfusion and oxygen delivery 6 Ley EJ, Clond MA, Srour MK, Barnajian M, Mirocha J, Margulies DR, et al. Emergency department crystalloid resuscitation of 1.5 L or more is associated with increased mortality in elderly and nonelderly trauma patients. J Trauma2011;70:
5 endotheliopathy 9 5
6 Ideal Resuscitation Fluid Predictable and sustained in intravascular volume Chemical composition like ECF Metabolized and completely excreted-without accumulation in tissues No adverse metabolic or systemic effects Cost-effective by improving patient outcomes Ideal Resuscitation Fluid 6
7 PolyHeme 12 No Ideal Solution Exists Crystalloid = Colloid - Neither superior - Systematic reviews of RCTs --> no difference Perel P, Roberts I. Colloids versus crystalloids for fluid resuscitation in critically ill patients. Cochrane Database Syst Rev 2012;6:CD Bunn F, Trivedi D. Colloid solutions for fluid resuscitation. Cochrane Database Syst Rev 2012;7:CD
8 Crystalloid 1/3 to ¼ remains intravascular Hence 500 ml bolus: ml x 0.25 = 125 ml Circulating plasma volume is ~5L (70 ml/kg IPBW) 2-3% increase in IV volume ph OSM
9 Best Crystalloid-0.9% NaCl? renal vasoconstriction renal injury hyperchloremic acidosis immunity renal perfusion fluid requirement - worse acidemia - hyperkalemia - coagulopathy - PRBC transfusion Best Crystalloid-LR? Less hyperchloremia Better buffer Can cause hyperlactatemia Is HYPO-tonic after infusion You CAN give LR w/blood transfusion Does NOT cause hyperkalemia in renal failure Not for bad TBI 9
10 ph OSM Best Crystalloid-PlasmaLyte-A? Most closely resembles plasma No Ca ++ so the worry warts have no fear with transfusion Slightly more expensive Maintains Mg levels in high volume resus Does NOT cause hyperkalemia in renal failure 10
11 ph OSM Better acid-base at 24 hours Less hyperchloremia No harm Cost analysis from their center: 11
12 12
13 TEG demonstrated hypercoaguability w/lr Hypocoag w/ns (acidemia and more volume) When do I give IVF for resuscitation? Evidence of shock or occult shock Primarily in trauma, burns and sepsis Hypotension <90 or <110s in severe TBI Lactate 2-4, >4 mmol/l Worsening base deficit < -3 mmol/l Decreased UOP (0.5 cc/kg/hr ideal predicted body weight) 13
14 Trauma Resuscitation Principles If bleeding, stop it, replace what's lost Fill the tank (but don t overfill) Perfuse the patient Monitor for response Should expect to see any/or a combo of the following: - increase BP - improved MS - decreased pulse - wider pulse pressure - improved UOP However these aren t the only indicators 14
15 Pressure Flow Perfusion Biochemical markers Base deficit Serum lactate Must be followed in tandem 15
16 30 SVV/ PPV UOP BP HR MS CVP? Echo Pulses BD Lactate Skin StO 2 ScvO
17 Why are we giving fluid? enhance oxygen delivery (DO 2 ) 17
18 Too much fluid? More: - $ - vent days - renal failure - ACS - anastomotic failure - etc 18
19 1. Should vascular access be attempted pre-hospital? 2. If obtained, at what site? 1. If 2 failed attempts I/O (Level II) 2. Limit attempts to 2 pre-hospital. If failed, use alternative (central or I/O). (Level III) 19
20 3. Should fluids be given? 1. Withhold in penetrating torso injury (Level II) 2. Saline lock = KVO (in patency) (Level II) 3. Withhold until hemorrhage control (Level III) 4. Titrate to radial pulse, use 250cc boluses (Level III) 4. What fluid? 1. Insufficient data to recommend one: Small volume 7.5% HTS = large volume isotonic Level I 2. Pre-hospital blood is safe and feasible (Level III) 20
21 5. If given, how much and how fast? 1. KVO adequate for injured patients (Level II) 2. Rapid infusion or pressure bags should not be used pre-hospital (Level III) 21
22 Mitch Cohen, UCSF 22 YOM Drugstore sales clerk ED by ambulance GSW lower abdomen during a robbery 9 mm handgun By ED arrival: lost ~ 2 L Conscious but disoriented Case Study BP 85/60 mm Hg HR 120 BPM RR 35 22
23 Acute Traumatic Coagulopathy (ATC) An endogenous impairment of hemostasis that occurs early after injury. Brohi K, et al. J Trauma. 2008;64: Hemorrhage and ATC Leading cause of death in 1 st hour of arrival Acosta JA et al J Am Coll Surg 1998 Responsible for over 80% O.R. deaths Kauvar DS et al J Trauma 2006 Accounts for 50% deaths in 1st 24 hours Hoyt DB et al J Trauma 1994 Sauaia A et al J Trauma
24 How acute and how lethal is ATC? 24.4 % (+) coagulopathic on admit Coagulopathy: higher mortality (46% vs. 11%) Brohi K et al J Trauma 2003 Retrospective, 1,088 trauma patients How fast and how lethal? 211 patients receiving MT or TEP Prevalence of coagulopathy 70% (INR>1.5) Mortality in non-coagulopathic 42% Mortality in coagulopathic 67% Cotton BA et al J Trauma
25 Risk Factors for ATC 1. Extent of tissue damage 2. Shock (SBP 90) 3-fold risk increase 3. Prehospital IV fluids 3,000 ml 4. Hypothermia (temperature 35 C) 5. Acidosis (BE <-10) 3-fold increase Wafaisade A, et al. Emerg Med J. 2010;27: Kauvar DS, et al. J Trauma. 2006;60:S3-S11. 25
26 Risk factors for ATC Brohi K et al J Trauma 2008 Risk factors for ATC Prevalence of Coagulopathy by ISS and BD in Patients Requiring a Blood Transfusion % with Coagulopathy >25 Injury Severity Score BD<6 BD 6 Niles SE et al J Trauma
27 27
28 From: The Prospective, Observational, Multicenter, Major Trauma Transfusion (PROMMTT) Study: Comparative Effectiveness of a Time-Varying Treatment With Competing Risks JAMA Surg. 2013;148(2): doi: /2013.jamasurg
29 A. Bryan Cotton 29
30 plasma, platelets, and PRBC ratio 1:1:1 vs 1:1:2 No differences in mortality at 24 hours or at 30 days. Better hemostasis in 1:1:1 Lower death due to exsanguination by 24 hours More plasma and platelets transfused in the 1:1:1 58 Summary Avoid NS in big trauma Plasmalyte-A may be best Use any crystalloid judiciously Stop the bleeding DCR Activate MTP s early Use all the controls in shock 59 30
31 60 31
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