ED • Consultant led trauma team • Dedicated trauma theatres & operating lists • All major specialties: • Ortho, general, vascular, neuro, plastics, cardiothoracic, head & neck, urology • Interventional radiology • Anaesthesia & Critical care Monday, 21 October 13
50%. 1 • (high volume > 20 cases per week) •Time from trauma to definitive surgery / intervention is the primary determinant of outcome in major trauma (not time to ED). 2 1. Relationship Between Trauma Center Volume and Outcomes. Nathens A et al, JAMA. 2001;285:1164-1171 2. Resources for Optimal Care of the Injured Patient. American College of Surgeons, 1999 • Monday, 21 October 13
in inadequate organ perfusion and delivery of oxygen •Classify shock •Haemorrhagic / hypovolaemic •Cardiogenic •Obstructive •Distributive •Septic •Neurogenic Monday, 21 October 13
a triangle Acute Traumatic Coagulopathy 25% trauma pts have established coagulopathy (ATC) on presentation - 4 fold increase in mortality Brohi K, Singh J, Heron M, Coats T. Acute traumatic coagulopathy. J Trauma 2003;54:1127-30. MacLeod JB, Lynn M, McKenney MG, Cohn SM, Murtha M. Early coagulopathy predicts mortality in trauma. J Trauma 2003;55:39-44. Maegele M, Lefering R, Yucel N, Tjardes T, Rixen D, Paffrath T, et al. Early coagulopathy in multiple injury: an analysis from the German Trauma Registry on 8724 patients. Injury 2007;38:298-304. SIRS CARS Monday, 21 October 13
ICS, College of EM following on from European Medicines Agency suspending marketing authorisation for HES due to risks outweighing any perceived benefits • Applies equally to pts with hypovolaemia, hypovolaemic shock, critically ill patients including those with sepsis, burns, trauma and those undergoing surgery Monday, 21 October 13
et al. Hydroxyethyl starch 130/0.42 versus Ringer's acetate in severe sepsis. N Engl J Med 2012;367:124-34. (6S Study) •2. Brunkhorst FM, Engel C, Bloos F, et al. Intensive insulin therapy and pentastarch resuscitation in severe sepsis. N Engl J Med 2008;358:125-39. (VISEP study) •3. Myburgh JA, Finfer S, Bellomo R, et al. Hydroxyethyl starch or saline for fluid resuscitation in intensive care. N Engl J Med 2012;367:1901-11. (CHEST Study) Monday, 21 October 13
no longer bleeding is easy • a patient with ongoing bleeding is much more complicated: huge potential to make the patient worse - your endpoints are much more important • Increasingly accepted view that moderate hypotension (Systolic <90mmHg) in trauma patients without TBI is sufficient to maintain critical organ perfusion (but pressure = flow) • Resuscitating to >90mmHg runs the risk of clot dislodgment & vicious circle formation Monday, 21 October 13
replacement, the ability to control ongoing blood loss is one of the most important determinants in the outcome of a seriously injured patient. Hess JR, Holcomb JB, Hoyt DB: Damage control resuscitation: The need for specific blood products to treat the coagulopathy of trauma. Transfusion 2006;46:685-6. Don’t obsess about fluid resuscitation ....control the source of bleeding Monday, 21 October 13
& is a major driver • Haemorrhage control is the priority • Do not delay transfer to place of definitive control transfer but use with caution • Permissive hypotension - arguable for - really relevant to prehospital • Clinical end points of resuscitation are uncertain - we are stuck with BP (Sys 100; Hb 7-8; plts100; INR<1.5; fibrinogen>1) Monday, 21 October 13
cells and clotting factors in trauma patients should be given in broadly similar proportions from the outset Borgman MA, Spinella PC, Perkins JG, Grathwohl KW, Repine T, Beekley AC, et al. The ratio of blood products transfused affects mortality in patients receiving massive transfusions at a combat support hospital. J Trauma 2007;63:805-13. Monday, 21 October 13
Perkins JG, Grathwohl KW, Repine T, Beekley AC, et al. The ratio of blood products transfused affects mortality in patients receiving massive transfusions at a combat support hospital. J Trauma 2007;63:805-13. Monday, 21 October 13
only describe isolated fragments of the haemostatic process •Always delays •Next set sent before first set back •If it were easy & quick - decisions about blood product ratios would not have to be pre- emptive Typical example of time to receiving PT result Monday, 21 October 13
CRASH 2 June 2010, The Lancet • Over 20,000 pts; 274 hospitals, 40 countries • Admin <8hrs from injury:1gm over 10mins & then 1gm over 8hours • Administration of Tranexamic acid reduced the risk of death in bleeding trauma victims (14.5% vs 16%) • No increase in vascular occlusive events Monday, 21 October 13
due to bleeding 5.3% (vs 7.7% placebo) • Rx 1-3hrs from injury: • Mortality due to bleeding 4.8% (vs 6.1% placebo) • Rx > 3hrs from injury: • Seemed to increase risk of death due to bleeding 4.4% (vs 3.1% placebo)......Unclear why Monday, 21 October 13
CRASH 2: 32% reduction in death if given <1hr • Give it ASAP (<3hrs) :1gm over 10mins (followed by 1gm over 8hrs) • Given early it effects ATC: prevents full activation of fibrinolysis which once started is difficult to abate • Pre hospital care may be where its role is best placed • Caution in those who present several hours after injury Monday, 21 October 13
care air transport team •Use of US & IO needles •Rx blast injury •Use of haemostatic dressings •PTSD LESSONS FROM CONTMEPORARY WAR Monday, 21 October 13
Early administration of blood: • Haemostatic resus • High ratio PRBC : FFP : Plts • Tranexamic acid • Damage control resuscitation & surgery (DCR / DCS) Monday, 21 October 13
haemostatic resus? • How do we identify them at the outset? • What is the optimal ratio PRBCs : FFP : Plts ? • Which pts will benefit most from permissive hypotension? • Precise indications for recombinant factor VII, tranexamic, cryo, calcium? • Does the storage age of the blood matter? Monday, 21 October 13
young people: haemorrhagic shock is the leading cause of mortality • Control of bleeding is paramount: therefore rapid transfer is a priority • Permissive hypotension has a role in pre hospital care • Coagulopathy develops early & is an independent risk factor for death - aggressive Mx • Tranexamic acid should be given early - ideally pre hospital • Lessons to be learnt from Military approach - but be objective: different patients, injuries & situation • Haemostatic resus: high ratio of products needed; likely 1:2; who stands to benefit most? • Further Evidence base is required Monday, 21 October 13
in Western World • Mortality due to sustained injuries (early) • Subsequent immune reactions (late) & resultant MOF • About 5% trauma patients develop post traumatic MOF Monday, 21 October 13
•physical condition Exogenous factors •Injuries themselves (1st hit: trauma load) •Resuscitation strategy & Surgery (2nd hit: intervention load) Organ damage & then failure is due to dysfunctional immune response Monday, 21 October 13