20131113 trauma christmas 2013

vooruitstrevend in perioperatieve zorgafdeling Anesthesiologie

TRAUMA

Holger Baumann MD

WHY TRAUMA?

Number 1 Killer

40 % uncontrolled hemorrhage

25 % coagulopathic in the ED

Krug, Am J Public Health 2000Sauaia, J Trauma 1995

Brohi, J Trauma 2003Maegele Shock 2006

Brohi, Curr Opp Crit Care 2007Frith, J Thromb 2010

Trauma & Coagulopathy

STOP The Bleeding Campaign

S creen for risk of bleeding/coagulopathty

T reat bleeding coagulopathy

O bserve response to intervention

P revent secondary bleeding / coagulopathy

Rossaint, Crit Care 2013www.advancedbleedingcare.org

STOP The Bleeding Campaign

Screen: Scores Labor

Treat: FFP Fibrinogeen TRX PCC rFVIIa

Observe: PT aPTT ROTEM/TEG

Prevent: Preconditions

Screen for risk of bleeding/coagulopathy

SCORES:

ABCPenetrating mechanism

ED SBP <90 mm

ED HR >120/min

Positive FAST

Nunez, J Trauma 2009 Cotton J Trauma 2010

Krumrei J Trauma 2012Yucsel J Trauma 2006

TASH

SCORES:

Trigger for MT

OR for MT 24 OR MT 24 +hemorrhagic death

OR MT 6 + hemorragic death

INR>1,5 2,2 2,5 3,9SBP < 90 mmHg 1,9 1,7 1,5Hb < 6,6 mml/l 1,8 1,8 2,0BD > 6,0 1,8 2,0 3,0HR > 120 bpm 1,1 1,2 1,2Penetrating 1,0 0,9 1,2dFAST + 1,9 1,8 1,9

Modified fromCalcutt, J Trauma 2013 (PROMMT)

MTS ≥ 2

MT 24 MT 24 + hemorrhagic death

MT 6 + hemorrhagic death

Sensitivity % 85 85 90

Specificity % 41 41 39

PPV % 31 33 39

NPV % 89 89 95

OR MT 3,9 3,9 6,0

Modified fromCalcutt, J Trauma 2013 (PROMMTT)

Base Deficite

BD <= 2 BD >2 - 6 BD >6-10 BD> 10Blood products 1,5 4,5 10,3 20,3

TASH Score 3,5 6,1 10,6 14,3Mortality % 7,4 12 23 51,3

Action? Watch Consider Act Prepare MTP

modifiedRec 11 Mutschler, Crit Care 2013

1C

Shock Index ?

BD≤2 BD>2-6,0 BD>6,0-10,0 BD<10,0 BD≤2 BD>2-6,0 BD>6,0-10,0 BD<10,0

SI < 0,6 SI 0,6-1,0 SI 1,0-1,4 SI ≥ 1,4 SI < 0,6 SI 0,6-1,0 SI 1,0-1,4 SI ≥ 1,4

modifiedMutschler, Crit Care 8- 2013

Conventioneel Lab. vs POC

Standard-Lab Point of Care(ROTEM/TEG)

Evaluatie voor bloeding NO YES

Tijd tot uitslag 30-60 min. 5-15 min.

Hyperfibrinolyse NO YES

Sterkte van stolsel NO YES

Conventioneel Lab. vs POC

Standard-LabPoint of Care(ROTEM/TEG)

Evaluatie voor bloeding NO YES

Tijd tot uitslag 30-60 min. 5-15 min.

Hyperfibrinolyse NO YES

Sterkte van stolsel NO YES

Logistics?Resources? Costs?QA?Training?

POC - thrombo…..• Admission Rapid Thrombelastography Can Replace Conventional Coagulation Tests

in the Emergency Department Experience With 1974 Consecutive Trauma Patients

• Trauma Bleeding Management: The Concept of Goal-Directed Primary Care / schochl

• Screenshots artikel / literture unten diskussion

Monitoring:

..routine practice include the measurement of INR, APTT, fibrinogen and platelets. INR and APTT alone should not be used to guide haemostatic therapy.

.. ..Thrombelastometry to assist in guiding haemostatic therapy.

modifiedRec 12 Spahn, Crit Care 2013

1C

2C

Holcomb, Ann Surg 2012

FIB. - CRYO - FFP

Fibrinogen FFP PCC

Content Fib. constant inconsistent constant

Time admission Immediately 30 min. Immediately

FFP’s – R24

Early treatment with thawed FFP in patients with massive bleeding. Initial dose is 10 to 15 ml/kg.

Spahn, Crit Care 2013

1B

PCC

+ -Rapid reversal of INR Verschillende concentraten

Small volume Prothrombotic risk ( 1,8%*)

No blood type matching No volume effect

Allercig effects?

*Dentali Thrombosis Hemost. 2011

PCC

Emergency reversal of Vit. K-dependent oral anticoagulants.

..PCC ..in the bleeding patient with thromboelastic evidence of delayed coagulaton ininiation.

Rec 31 Spahn, Crit Care 2013

1C

1B

Tranexminezuur (TRX)

..as early as possible to the bleeding patient

..within 3 h after injury

Consider TRX en route to the hospital

Rec 31 Spahn, Crit Care 2013

Tranexminezuur (TRX)

1A

1B

1C

Observe Response to Intervention

• Clinical

• ROTEM

•

Prevent secondary coagulopathy

• Damage control

• Rewarming

• Restore physiology

• No delay

‘De drie eenheid’

Hemodilutie - BloedproduktenWhole blood – 1:1:1 approach

650 ml koud spulHb 5.5 mmol/l (8.9 g/dl)Thr. 75 * 109 Plasma factors 70 %Fibrinogen: 0,5 -1 g (?)

Armand, Transf Medicine Reviews 2003 Como, Transfusion 2004

500 mL Warm500 mL WarmHct: 38-50%Hct: 38-50%Plt: 150-400K Plt: 150-400K Coags: 100%Coags: 100%

1500 mgFibrinogen

Massaal bloedtransfusie protocol @

How do u sweet’n your coffee?

rFVIIa in Trauma

Consider rFVIIa after “conventional” therapy,

if

rFVIIa(Novoseven): 90micg/kg BW

pH > 7,2Temp. > 35,0CFibrinogen > 100 mg/dl or FIBTEM >12 mmThrombocytes > 50/nl or Extem > 45mmHyperfibrinolysis ruled out/therapy

No surgical/IR therapy

REC 33: Spahn, Crit Care 2013

2C

Zorg voor heldere lokale protocollen.Multidisciplinaire aanpak

Voorlichting en training Behandel coagulopathieën

• Basale behandeling• TRX• FFP/FIB• MTP • rFVIIa

A failure in planning is a plan for failureS03E08 Star Wars The Clone Wars

En nu?

vooruitstrevend in perioperatieve zorgafdeling Anesthesiologie

Fibrinogen / Cryoprecipitate

Recommendation 26. We recommend treatment with fibrinogen concentrate or cryoprecipitate if significant bleeding is accompanied by thrombelastometric signs of a functional fibrinogen deficit or a plasma fibrinogen level of less than 1.5 to 2.0 g/l (Grade 1C).

No trauma trials - extrapolation from haemophilia and congenital afibrinogenaemia

Probably give if fibrinogen < 1 g/l

Dose - know your local formulation (cryo not licensed outside UK). Enough to give > 1 g/l

Recommendation

RBC’s Hb 4,4-5,6 mmol/l 1C 17 ATIII No 1C 26

DDAVP Not routinely 2C 30

Platelets > 50000 > 100000 in TBI

1C2C 28

Calcium ≥ 1,0 mmol/l 1C 25