TRAUMA: NO DRAMA! CASES FROM THE ER Whistler, BC, February 2014 University of Toronto Emergency Medicine Conference

Transcription

1 TRAUMA: NO DRAMA! CASES FROM THE ER Whistler, BC, February 2014 University of Toronto Emergency Medicine Conference Mike Brzozowski Sunnybrook Health Sciences Centre Toronto, Ontario

2 Conflicts of Interests: I wish! None to Declare

3 OBJECTIVES: To review some recent developments in the field of trauma management in a case based format To review the approach to management of some challenging cases with traumatic injury

4 CASE 1 34 year old male, driver skier vs telephone post chairlift pole. VS : 130/80, 75, 16, O2 sat 98 % C/O central chest pain No other obvious injury

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7 SO, WHAT AM I WORRIED ABOUT AND WHAT DO I DO ABOUT IT? Blunt Cardiac Injury Blunt Aortic Injury

8 SPECTRUM OF BLUNT CARDIAC INJURY Bruise Valvular Disruption Free wall Concussion Septal Rupture Rupture Contusion Coronary Artery Injury Myocardial Hemorrhage Cardiac (Pump) Failure Complex Arrhythmias Pericardial Tear

9 BLUNT CARDIAC TRAUMA n Significant structural injuries are obvious: u Hypotension u CHF u New Murmurs

10 MYOCARDIAL CONTUSION n blunt chest trauma with cardiac complications n Most common complication: arrhythmia

11 BLUNT CARDIAC INJURY n CXR n EKG n Cardiac Enzymes n ECHO

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13 MYOCARDIAL CONTUSION: CXR Primarily gives us indirect information regarding peri-cardiac injury Rib # s, Pneumo/Hemothorax, Contusion

14 MYOCARDIAL CONTUSION:EKG n Most would recommend that if initial EKG normal, discharge is appropriate +/-(observation?) n Very few reports in literature of complications n Most complications occur within first 12 hours

15 ekg contusion.jpeg

16 MYOCARDIAL CONTUSION:EKG EKG Abnormal Most common: ST-T Wave changes Ischemic changes RBBB, PVC s ST, A-fib, A-flutter, Junctional, VT/VF If Abnormal? Observe +/-ECHO

17 MYOCARDIAL CONTUSION: ENZYMES? Would you draw a CK MB or a Troponin? High sensitivity Troponin = < 5 Normal EKG AND negative Troponin I =100% rules out BCI New high sensitivity troponin? Timing unknown

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19 MYOCARDIAL CONTUSION: ECHO? n Most common ECHO abnormalities t RV dyskinesia t trace pericardial fluid n abnormal ECHO not predictive of clinical outcome

20 ECHOCARDIOGRAPHY IN BLUNT CARDIAC INJURY Indications for Echocardiography: n?abnormal EKG and or +Troponin n Clinical signs of cardiac dysfunction t murmur t low cardiac output n Unstable patient with unexplained hypotension t pericardial effusion & tamponade t structural injury (valves, interventricular septum) t free wall rupture

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22 CONCLUSIONS: n Is there a gold standard? n Best predictive test to date? n Complications with normal EKG? AUTOPSY EKG LOW n Troponin? REASSURANCE n Prognosis rather than diagnosis? YES EAST Guidelines, J of Trauma Acute Care Surg, Vol 73, Number 5, Supplement 4

23 WHAT ABOUT THE STERNAL FRACTURE? Isolated Injury vs Polytrauma Patients with isolated injury had no incidence of ET Intubation or chest tube insertion 16 % with Polytrauma

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25 BLUNT AORTIC INJURY n significant injuries die at the scene n Mechanism: MVC, falls, pedestrians, thoracic crush injuries n Often multiple injuries n Requires high index of suspicion

26 BLUNT AORTIC INJURY Most common location: descending aorta distal to the left subclavian artery (ligamentum arteriosum) Management n primarily surgical n Address other traumatic injuries n Medical stabilization: u Beta-blockade u Nitroprusside

27 BLUNT AORTIC INJURY CXR (upright PA is best) Wide mediastinum Pleural cap Obscured aortic knob Deviation of L main bronchus or NG tube Opacification of the AP window?rib # s May still miss 10% with NORMAL CXR

28 BLUNT AORTIC INJURY Who do I need to screen? I don t know. Significant Chest trauma Associated/Multi-System Trauma Mechanism of Injury

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30 CASE 2 78 year old woman, tripped on 6am?LOC Seen by FMD and advised to go to ER Instead, went home and developed headache and vomiting Presented to ER with GCS 7 PMHx: Afib, Meds: Coumadin

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32 CASE 2 Intubated and ventilated INR = 2.25 What do we do now?

33 PROTHROMBIN COMPLEX CONCENTRATE Octaplex (Beriplex) Pooled human blood product Eight components

34 PROTHROMBIN COMPLEX CONCENTRATE Factors II, VII, IX and X Protein C and S Heparin Citrate Indications: Primarily for rapid reversal of anticoagulated patients (on Coumadin), in the face of life threatening hemorrhage or surgery

35 PROTHROMBIN COMPLEX CONCENTRATE Dosing is weight related, and INR dependent Based on the Factor IX content Each vial contains 500 IU of Factor IX (20 mls/vial) kg, INR IU (40 mls) kg, INR > IU (80 mls) >90 kg, INR > IU (80 mls) Infuse 150 mls/hr Immediate onset of action

36 PROTHROMBIN COMPLEX CONCENTRATE Repeat INR post infusion If INR still greater than 1.5, infuse an additional 1000 IU s Maximum single dose 3000 IU Concomitant dose of 10 IU Vitamin K PCC duration of action 6-12 hours Vitamin K effect has hopefully kicked in by then

37 PROTHROMBIN COMPLEX CONCENTRATE Back to our patient...octaplex was given INR =1.85 Neurosurgery preparing for the OR Repeat dose of Octaplex administered INR 1.27 To OR for craniotomy

38 PROTHROMBIN COMPLEX CONCENTRATE What if you don t have it? Nearly all hospitals in Ontario have it Last Resort : FFP (4 units if you re a big person, 3 if you re little)

39 WHY USE PCCS VS. FFP? PCC FFP Pooled, virally inactivated Prion reduction process Lyophilized Needs to be reconstituted Volume 40-80mL Infused over 15-30min Less risk of transfusion rxns Not virally inactivated Needs ABO group (10min) Needs to be thawed (30min) Volume 15mL/kg (~1000mL) Infused over hours Risk of transfusion rxns: TRALI, TACO, anaphylaxis $1150 for 1000 units $1050 for 6 units plasma Only lasts 6-8 hours

40 SO WHAT IF OUR PATIENT IS ON ASA OR PLAVIX??

41 WHAT IF OUR PATIENT IS ON ASA OR PLAVIX? Probably a good idea to talk to your hematologist No compelling evidence for platelet transfusion If bleeding is uncontrolled :?2 pooled units of plts DDAVP? TXA

42 WHAT IF OUR PATIENT IS ON PLAVIX OR ASA?

43 OR WORSE? New Oral Anticoagulants!!! Dabigatran, Rivaroxaban, Apixaban

44 NEW ORAL ANTICOAGULANTS n Used in Afib. and VTE n No monitoring required n lower rates of stroke and severe bleeding n No reversal agents n Dabigatran, Rivaroxaban, Apixaban

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46 GREAT! NO REVERSAL AGENT?.NOW WHAT DO I DO WITH A SEVERELY BLEEDING PATIENT ON THESE DRUGS?? n Consult transfusion medicine/hematology n They re going to want to know the PT, CBC, and time of last dose n Consider anti-fibrinolytic therapy (TXA) n Control bleeding (surgery or embolization) n Transfuse PRBC and platelets, if needed n No need for Plasma, Cryoprecipitate Baumann Kreuziger et al. New Anticoagulants: A concise review. J Trauma 2012; 73:

47 ORAL ANTICOAGULANTS Antidote = TIME Transfuse RBC s and Platelets as needed Consider oral charcoal if overdose < 2 hours ago Consider PCC If available, consider apcc (Factor Eight Inhibitor Bypass Agent) For Dabigatran:? dialysis

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49 CASE 3 49 yo male EM doc/ttl decides it s a good idea to ride Soudan Couloir, as he did 20 years ago Not such a great choice

50 CASE 3 VS by EMS: BP 130/80, HR 100, RR 10, GCS 14 Primary survey: A, B, C OK Secondary survey: Large scalp laceration, multiple abrasions, clinically stable pelvis, gross hematuria CXR = Normal, FAST positive in Morison s Pouch Pelvic # Brief episode of hypotension (85/60), responded to bolus of R/L

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52 WHAT TO THINK OF THE EPISODE OF HYPOTENSION?

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54 J TRAUMA JUNE 2010 N=145 Looked at pts with single SBP reading < 110 mmhg (not persistent ê BP) 38% of those with single SBP < 105 mmhg required immediate OR/angio (vs 10% for those mmhg)

55 CASE 3 Patient taken to CT for the usual CT Head: Left tempoparietal SDH, SAH, contusion CT Abdomen: Small liver laceration, Large RPH with no active extravasation Now BP falls again, 90/70, again transient response to fluids Initial Hb 137

56 CASE 3 OK, now BP is really not responding to 2 litres if R/L given Awaiting Angio and Embolization What else can we do with this patient? Tranexamic Acid Blood Product Transfusion

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58 TRANEXAMIC ACID IN THE BLEEDING PATIENT ~1/3 of trauma deaths due to hemorrhage Similar hemostatic responses to both major surgery and trauma Trigger fibrinolysis and pathologic hyper-fibrinolysis Tranexamic Acid (TA) is a synthetic derivative of the amino acid lysine that binds the lysine binding sites on plasminogen Similar response in trauma?

59 CRASH 2 TRIAL LANCET, VOL 376, JULY 3, Clinical Randomisation of an Antifibrinolytic in Significant Haemorrhage 274 hospitals, 40 countries Trauma patients with significant hemorrhage SBP < 90, HR > 110 Or clinician felt patient at risk of significant bleeding Within 8 hours of injury

60 CRASH 2 TRIAL Results: Overall reduction in mortality in TA group 14.5% vs 16% (RR 0.91) p Only statistically significant subgroup with lower death rate was those with death due to bleeding No increase in vascular events causing death No change in blood products administered

61 CRASH 2 TRIAL : SECONDARY ANALYSIS All cause mortality by subgroups All did better with TXA, except time from injury > 3 hrs So...if you re going to use it, use it early!

62 CRASH 2 TRIAL So... Seems to be safe Somewhat efficacious Cheap Kind of like giving chest pain patients ASA??

63 TRANEXAMIC ACID Any reason not to use it? Gross hematuria (relative) Risk for vascular events

64 WHAT DO I GIVE TO MY BLEEDING TRAUMA PATIENT??? I don t know TXA Crystalloid Blood products YES, but which ones and what ratios?

65 DAMAGE CONTROL RESUSCITATION (DCR) Optimal blood component transfusion ratios? 1:1:1 (PRC, FFP, Plts)? Patient selection a challenge Numerous retrospective studies reporting decreased mortality with higher FFP to RBC ratios

66 DAMAGE CONTROL RESUSCITATION (DCR) The Coagulopathy of Trauma: A Review of Mechanisms. Hess, J. Holcomb, J. J of Trauma. Oct 2008 Vol. 65, No.4. DCR: A sensible approach to the exsanguinating surgical patient. Beekley A., Crit Care Med, 2008 Vol 36, No. 7 (Supp) Effect of a fixed-ratio (1:1:1) transfusion protocol vs. laboratory-results-guided transfusion in patients with severe trauma;: a randomised feasibility trial. Nascimento et al. CMAJ 2013; 185(12): E583.

67 SNYDER, C. ET AL. THE RELATIONSHIP OF BLOOD PRODUCT RATIO TO MORTALITY: SURVIVAL BENEFIT OR SURVIVAL BIAS? J OF T. VOL.66, NO. 2. FEB Looks at the effect of timing of therapy initiated and survival Patient transfusion requirements and survival calculated at 24 hours Deaths < 6hrs: Low 33/43 High 3/24

68 SNYDER: DCR AND SURVIVAL BIAS Conclusions: Non survivors in this study did not die because they got a lower FFP:RBC ratio, but rather got a lower FFP:RBC ratio because they died! Best ratio of FFP to PRC to Plats yet unknown

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70 CRYSTALLOID TO BLOOD PRODUCT RATIO Give the patients what they want (and need)!

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72 J TRAUMA APR 2012 N=452 massive transfusion pts ( 10U PRBCs in 24 hrs) Crystalloid:PRBC ratio > 1.5:1 had higher rates of multisystem organ failure (OR 1.7), ARDS (OR 2.2) and ACS (OR 2.3) But, no effect on mortality

73 SO Start with crystalloid, 1-2 litres Observe response Usually happy with a normal Mental Status and a radial pulse Early administration of TXA Blood, and likely FFP and Platelets earlier in patients at risk for Massive transfusion

74 SUMMARY: Chest injury: Mechanism of Injury and Poly-trauma most likely associated with more severe cardiac and vascular injuries Normal EKG and Troponin are reassuring Patients with Closed Head Injury and Intracranial Bleeding: Likely, the reversal of Coumadin is the only proven efficacious therapy Hemorrhagic shock patients: Trial of Crystalloid with early Balanced Transfusion likely beneficial Don t forget the TXA! Cheap, easy and low risk

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