blood and trauma update 2016 - society of intensive care medicine symposium

Blood Trauma

SISPO 2016

Tan Hon Liang

Dr. Kang Mo-yeon

Role of CPR in trauma?

No conflicts of interest to declare

World War 1

Basic first aid

Some blood, some fluid, some surgery

3L crystalloid, 1L bloodSurgery

Birth of ATLS

Crystalloid, RBC, PlasmaDamage control resuscitation

Damage control surgery

What do we know?

Trauma

BleedingTBI Chest Abdomen LimbsPelvis

Die

ATLSInvestigationsInterventions

Medical Surgical

Blunt vs Penetrating

ATLS

4 yearly review

Financial gains

Target audience

Dogma/Myth

Up to Date?

Cervical Collar

Resuscitative Endovascular Balloon Occlusion of Aorta (REBOA)

Trimodal Distribution?

Trimodal Distribution?

Shock Classification?

Shock Classification?

Shock Classification?

>30,000

Manual in-line stabilization

Rapid Sequence Induction

Glasgow Coma Scale

18 possible permutations exist for GCS 9

17 for scores 8 and 10 14 for scores 7 and 1110 for scores 6 and 12

ATLS <=> EGDT

ATLSInvestigationsInterventions

Medical Surgical

What do we know about blood and trauma circa 2015

CoagulopathyAcidosis Hypothermia

TAC

Platelet defect (TBI)Consumption (Clot/DIC)Endothelial injury, Fibrinolysis

DCRMedical - Blood/drugSurgical - Laparotomy vs conservative

12 Apr 2016

37 Recommendations

Systolic blood pressure 80-90 mmHg (no TBI).

Mean arterial pressure of 80 mmHg (if TBI present)

“Restrained resuscitation” “Permissive hypotension”

Highlights

Recommendation 13

At least 1:1:1

Highlights

Recommendation 24

95.1% of 245 trauma centers - massive transfusion protocols 67.7% tended toward 1:1:1 ratios

Highlights

Recommendation 25

Tranexamic acid

< 3 hours1 g load, 1 g over 8 hr

Developing countries (245 centres in 40 countries)

Methodology(selection, randomization)

(no phone!)

100% follow up

Complication screening

CRASH-2 Critics

Advanced Trauma Centres

Complication screening

CRASH2 MATTERsNNT 67 7

MortalityBenefit 1.5% 6.7%

Seriously injured

Retrospective

MATTERs

Highlights

Recommendation 28

Recommendation 29

Recommendation 31

Low fibrinogen: 15-20 units of Cryoprecipitate

Platelets: >50 or >100 if TBI or on-going bleeding

Anti-Platelets: give platelets

Recommendation 32Known platelet dysfunction: desmopressin (0.3 mcg/kg)

Highlights

Recommendation 33

Recommendation 34

Recommendation 35

PCC if Warfarin

FXa inhibitors: TXA and high dose PCC

Thrombin inhibitors: idarucizumab or TXA and high dose PCC

Recommendation 36Off label rFVIIa only if desperate

What do we know?

1:1:1Cryoglobulin

Calcium

TemperatureAcidosis

“Limit” crystalloidsStop bleeding

TXAReversal agents

ATLS = BasicMore TXA evidence coming

NOAC situations = new approaches

@HonLiangTantanhonliang@gmail.com

tan.hon.liang@singhealth.com.sg

SGicu.com