Hemostatic Resuscitation 30 th David Miller Trauma Symposium Bill Beck, MD Assistant Professor of Surgery Trauma, Emergency General Surgery, Critical Care
Disclosures None Again. Mac user.
Why I Like Trauma?
Background Hemorrhage is responsible for >80% of trauma OR deaths and >50% of deaths in the first 24 hours after injury. Rapid identification of coagulation abnormalities appears critical to improving survival Most current transfusion protocols are not individualized https://www.ncbi.nlm.nih.gov/pubmed/7869433
1980 s https://www.ncbi.nlm.nih.gov/pubmed/7869433
1980 s
The best prehospital fluid is diesel fuel -Ken Mattox, MD
90 s/2000 s
Just Give Them Blood. 2-6 x increase SIRS 4 x increase in ICU Mortality 3.5 x increased odds ratio of infection https://www.ncbi.nlm.nih.gov/pubmed/20051407 https://www.ncbi.nlm.nih.gov/pubmed/15761334 https://www.ncbi.nlm.nih.gov/pubmed/12777903
Defining the Massively Transfused > 20 units in 24 hours, or one circulating blood volume > 10 units in 24 hours (2010-Nunez) https://www.ncbi.nlm.nih.gov/pmc/articles/pmc3136378
Epidemiology MTP in 3-5% of civilian trauma patients 25% of patients needing MTP have evidence of coagulopathy This group consumes 75% of all blood products in trauma centers. https://www.ncbi.nlm.nih.gov/pmc/articles/pmc3136378
To improve survival, transfusion ratios were protocolized. https://www.ncbi.nlm.nih.gov/pubmed/18469638 https://www.ncbi.nlm.nih.gov/pubmed/18695461 https://www.ncbi.nlm.nih.gov/pubmed/17215741 https://www.ncbi.nlm.nih.gov/pubmed/18784564 https://www.ncbi.nlm.nih.gov/pubmed/18545109
PROPPR Evaluated ratio of 1:1:1 to 1:1:2 for Plasma:Platelets:PRBC 680 patients No mortality difference at 24 hours and 30 days Fewer deaths by exsanguination and more achieved hemostasis in 1:1:1 No differences in safety events, although 1:1:1 received more products https://www.ncbi.nlm.nih.gov/pubmed/25647203
When to activate? Earlier activation is better (ABC) Usually no lab values back
Assessment of Blood Consumption for MTP Penetrating Mechanism ED Systolic BP < 90 ED HR > 120 FAST Get 1 point for each positive finding >2 Points correctly classified 85% of people needing MTP If negative, this does not mean the patient will not need blood, just unlikely to require massive transfusion https://www.ncbi.nlm.nih.gov/pubmed/19204506
Variability Despite all evidence and multiple scoring systems, < 50% of all activations occurred in the ED. https://www.ncbi.nlm.nih.gov/pubmed/19131804/
Turns out, that s bad. 680 pts with MTP Patient arrival to call = 9 min ; 8 min to cooler arrival Every minute delay increased MORTALITY by 5%
What can I do? Establish MTP protocols Follow said protocols Keep blood products in the ED ACTIVATE PREHOSPITAL (ABC) 60% odds reduction in 30-day mortality when controlling for admission injury severity and physiology (thawed plasma)
Assessment of Blood Consumption for MTP Penetrating Mechanism ED Systolic BP < 90 ED HR > 120 FAST Get 1 point for each positive finding >2 Points correctly classified 85% of people needing MTP If negative, this does not mean the patient will not need blood, just unlikely to require massive transfusion https://www.ncbi.nlm.nih.gov/pubmed/19204506
Courtesy of Bryan Cotton
ROTEM Thromboelastometry - technology
PT, aptt Limitations PT/aPTT do not reflect fibrin polymerization, FXIIIa or fibrinolysis Thrombin generation PT, aptt Thrombin generation continues / building clot (with fibrinogen, platelets and FXIIIa) Thrombin generation needed to start clotting
N=1262 INR > 1.4 PTT > 35 https://www.ncbi.nlm.nih. gov/pubmed/28338598
The graph information or TEMogram Time (in sec)) Amplitude in (mm) The greater the amplitude the firmer the clot The graph demonstrates the change in amplitude (clot firmness) over a time period
TEG Phenotypes 180 patients 21% penetrating ISS > 15 10% with hyperfibrinolysis 60% of patients had fibrinolysis shutdown https://www.ncbi.nlm.nih.gov/pubmed/25051384
Cause of death is different Fibrinolysis patients die from hemorrhage Shutdown patients more commonly die from organ failure https://www.ncbi.nlm.nih.gov/pubmed/25051384
Hyperfibrinolysis 84 patients, 42 matched pairs 17% patients with hyperfibrinolysis Death Diamond 100 % specificity for death Consumed 4 x blood products http://www.ncbi.nlm.nih.gov/pubmed/26488324
Hyperfibrinolysis Detection of Hyperfibrinolysis 118 patients, highest activation, LA County, ~ 10% with hyperfibrinolysis 62% of these patients dead at 6 hours Greater need for massive transfusion (3/4 with hyperfibrinolysis vs 1/10 without evidence of hyperfibrinolysis) http://www.ncbi.nlm.nih.gov/pubmed/22766227
Can replace conventional coagulation tests in ER 1974 consecutive trauma patients in Houston Compared to conventional coagulation studies including fibrinogen Controlled for age, sex, MOI, base deficit, revised trauma score, and ISS all rteg values were predictors of 24 hour and 30 day mortality Only PTT was predictor from conventional tests rteg results delivered faster http://www.ncbi.nlm.nih.gov/pubmed/22868371
The graph information or TEMogram CT = 0-2 mm The broken green lines provide a marker at 40mm for an easier visual estimation of amplitude The graph and TEMogram provides colors and other visual markers to aid in the rapid assessment of the developing clot.
The graph information or TEMogram CFT = 2 20 mm The broken green lines provide a marker at 40mm for an easier visual estimation of amplitude The graph and TEMogram provides colors and other visual markers to aid in the rapid assessment of the developing clot. PR2013-09v01
The graph information or TEMogram Firm & Stable Unstable (early Lysis) Relatively Weak
CT CFT α PLASMA ML TXA A10 A20 MCF PLATELETS FIBTEM Cryoprecipitate
ROTEM Interpretation If this is prolonged, give FFP Measured Parameter CT (sec) Clinical Significance Clot Initiation IN = 122 208 EX = 43 82 CT Measured in (sec) - Reflects the patients ability to generate thrombin resulting in the onset of clot formation
ROTEM Interpretation If this is low, need platelets (fibtem normal) and cryo (fibtem abnormal) Measured Parameter CT (sec) Clinical Significance Clot Initiation A10 (mm) Clot Firmness A10 = 40-60 Amplitude (A10, A20 & MCF) Measured in (mm) - Reflects the firmness and stability of a clot i.e. interaction of platelets, fibrin and FXIIIa.
ROTEM Interpretation If ML > 3% then need TXA Measured Parameter CT (sec) Clinical Significance Clot Initiation A10 (mm) Clot Firmness ML (%) Clot Lysis Maximum Lysis ML Measured in (%) - Reflects the degree of clot lysis ML = > 15%*
Clot Retraction not Lysis
Platelets contribute 80% of overall clot strength; remaining 20% is contributed by the fibrin network. 40
The important takeaway information Learn to recognize what Normal looks like Keep it simple to start: CT/CFT Thrombin Generation PLASMA (PCC) A10 Amplitude / Clot Firmness PLT/CRYO ML Clot Lysis PRESCRIPTION (TXA) PR2013-09v01
Questions? Bill Beck wcbeck@uams.edu @bill_bec