damage control resuscitation -...

Damage Control ResuscitationVGH Trauma Rounds 2018Harvey Hawes

Example Case

● 25yo F in motor vehicle collision at high speed● Picked up at scene by Helicopter EMS unit

○ Initial vital signs:■ HR 134■ BP 88/42■ GCS 10/15

● What is the primary problem here?

Example Case

A. What would you instruct paramedics to do next?

a. Nothing, just transport patient rapidly to hospital

b. Give 2L saline IV wide-open

c. Give 2 units packed red blood cells and 2 units of FFP

The “old” days

Crystalloid resuscitation

“Preload directed” or Supranormal resuscitation came in the 1990s

Delivery of Oxygen Index (DO2I) was calculated via a Swan-Ganz

● Target of >600 ml/min⋅m2

Many litres of crystalloid given to achieve this

Blood reserved for “refractory” bleedingShoemaker, et al. Chest. 1998.

Crystalloid Era

• Typical post-operative scenarios were seen

Debunked

… but we had it right 80 years earlier

The “old old” days

The “old old” days

Charles Best Norman Bethune

How did we get it wrong?

Trauma systems were evolving

Prehospital became a thing

War surgeons were returning to inner city war zones

Intensive care units being developed

Mortality rates were falling for many reasons

Mor

talit

y

Time

How did we get it wrong?

Shires believed that the interstitium needed to be resuscitated first, before giving blood products

This is the paper where the ATLS 2L of saline come from

● Different in ALTS 10th Ed

How did we get it wrong?

Fractionation of whole blood

Components marketed as allowing clinical flexibility

Better storage of some products

Increased revenue of mostly private blood banks

This is not blood

Houston: 2011 - 2012

Four Studies

Four Studies

Four Studies

Four Studies

Bonus Study

Underrated study, but most important to Holcomb...

Damage Control Resuscitation

• Benefits– Improved survival of the highest ISS patients

– Less blood product use (how?)

• Quicker normalization of coagulopathy

• Less “wasted” blood products

– Less open abdomens

Physiologic Benefits• Many theories now being developed to explain findings

– “Endotheliopathy”- inflammatory damage to microvessels

• Repaired by FFP, cryo and dried plasma, whole blood

• Worsened by crystalloid

– Supporting and maintaining initial clot

• TXA, fibrinogen

Risks of Crystalloids

• Crystalloid resuscitation:– Volume of crystalloids are linearly related to mortality– Is acidotic– Dilutes clotting factors– Damages vessel endothelium– Contributes to CRALI (Cotton’s retort to TRALI)

… back to our case

Example Case

● 25yo M in motor vehicle collision at high speed● Picked up at scene by Helicopter EMS unit

○ Initial vital signs:■ HR 134■ BP 88/42■ GCS 10/15

Example Case

● During Helicopter transport

○ FAST Ultrasound positive for blood in abdomen○ 2 units of PRBCs and FFP transfused○ Hospital contacted and Massive Transfusion Protocol activated

Example Case

● Patient arrives to hospital○ Vital Signs:

■ HR 115■ BP 108/55

● What do you do next?

Example Case

● ATLS primary and secondary survey completed

● Chest tube placed (500cc blood out)

● Chest X-ray, Pelvis X-ray done, FAST +

● Vital signs:○ HR 118○ BP 90/50

● 14 minutes has elapsed since arrival to hospital

Example Case

● This patient met our criteria for massive transfusion● Trauma blood bank at bedside opened on arrival● Continued with Platelets, FFP and PRBCs● Patient stable enough for CT scan in trauma bay

Example Case

Example Case

● Left hemothorax – resolved with chest drain● Blunt liver injury (Grade III)● Right renal injury (Grade II)

● Juxtarenal IVC injury with large hematoma

Example Case

● Vital Signs:○ HR 108○ BP 117/78

● Total transfusion now at 5 units PRBC, 5 units FFP and 5 units of Platelets● Total time elapsed 40 minutes

● What would you do next?

Example Case

Patient transferred to STICU for observation (!?!?!?)

● TEGs and VBG normalized within 3 hours● Did not require laparotomy● IVC filter placed above IVC injury● Eventually discharged home on oral anticoagulation● Filter taken out day 30

Example Case - Points

This is a case of DCR providing “Control of Bleeding” without intervention

● Early (pre-hospital) detection of hemorrhagic shock● Damage Control Resuscitation

○ 1:1:1 ratio of blood products used○ 660cc of crystalloid used from field to STICU

● Restoration of coagulation system● No laparotomy needed

Principles

How do we do it?

Principles

1. Rapidly identify need and activate protocol

2. Permissive hypotension

3. Resuscitate blood loss with whole blood

4. Do not delay hemorrhage control

Principles

1. Rapidly identify need and activate protocol– Good understanding of causes of shock in trauma

• Hemorrhagic, hemorrhagic, hemorrhagic

• Obstructive (Tension PTX, Tamponade)

• Distributive (Brain or spine) – HR 70, SBP 70

– Need scoring system

• ABC score, Shock Index, etc

Principles

1. Rapidly identify need and activate protocol– ABC score (Assessment of Blood Consumption --aka “Angry Bryan

Cotton”)

– Two of:

● SBP < 90mmHg

● HR > 120bpm

● Penetrating Trauma

● Positive FAST exam

Principles

1. Rapidly identify need and activate protocol– Don’t wait for blood work!

• VBG – look at Base Deficit to monitor resuscitation

• Type and Screen– Don’t wait for it. Give Universal Donor

• INR/PTT, Hgb only useful if medical comorbidities– Coumadin use– Normal INR/PTT means little about clot formation and strength

Principles

2. Permissive hypotension– Accept systolic BP around 90mmHg

• Except for brain or spine injury

– Don’t “pop the clot”

– Don’t waste products

Principles

3. Resuscitate blood loss with blood– NO CRYSTALLOID!

• Kills bleeding patients

• Furthers endothelial damage

• Dilutes clotting factors

• Use it only after bleeding is stopped

• Need to limit use in the field

• The sweet spot is likely ~1L prior to hemorrhage control

100 ml

Principles

3. Resuscitate blood loss with blood– What to give and when?

– How to give it?

– When to stop?

Principles

3. Resuscitate blood loss with blood– What to give and when?

• Resuscitate coagulation system– Replenish coagulation factors

– Reverse acidosis

– Replenish platelets early

• Early FFP and Platelets saves lives

Principles

3. Resuscitate blood loss with blood– What to give and when?

• Resuscitate O2 carrying capacity– Give RBCs as needed

– “Don’t pour Red Cells out a hole”

Principles3. Resuscitate blood loss with blood

– What to give and when?

• Simple protocol to use while bleeding

• Protocol stops when surgical control of bleeding achieved

1:1:1

NOTE - (FFP:Plts:RBC)

• The ratio is roughly recreates whole blood– 6 units FFP (sometimes come as “doubles”)

– 6 units Plts (pooled suspended in plasma)

• The fastest available product!

– 6 units PRBC

– Think of them as 6:6:6 – in the box

“Anemic, cold, acidotic, old blood”

Principles

3. Resuscitate blood loss with blood– What to give and when?

• Adjuncts– Cryoprecipitate? (or Fibrinogen Concentrate)

• Yes, but what form and when?

– Tranexamic acid?

• Yes, but in the first 3 hours

– Octaplex/PCCs?

• Maybe in the near future

– Factor VIIa?

• Not anymore

Principles

3. Resuscitate blood loss with blood– How to give it?

• Warm!

• Fast!

• Level 1 rapid infuser

• That means BIG IV’s, Humeral IO, or Cordis

– An 18ga is NOT a big IV!

Principles

3. Resuscitate blood loss with blood

Principles

3. Resuscitate blood loss with blood– When to stop?

• When control of bleeding achieved

• No cardiac activity

• Keep real-time count!

FFP

PLTs

PRBC

Principles

A satisfying resuscitation

This is why flow rates matter

● Each bag is ~400ml

Principles… but that’s just straight 1:1:1

Can we have more guidance?

● INR/PTT? - To slow, not granular enough● ROTEM / TEG - Rapid, multifactorial, repeatable, cheap

Can tailor products to actual data

Fibrinogen, Platelets, Plasma, TXA

Expanded role of DCR?

● Sepsis resuscitation● DIC resuscitation*● Amniotic fluid embolus*● GI bleed*● PPH*

Evidence starting to come out for some of these indications

Remote DCR

What if you in a rural setting, or the field?

● 2 units of blood in many Level V hospitals● Long transport times● Do you give crystalloid? How much? When?● 2018 THOR consensus statement: Prolonged SBP < 100mmHg detrimental● Rapid Transport and controlling the bleeding important (tourniquet, REBOA)

Cold-stored Whole Blood (CWB)

Why do we have to use fractionated blood?

● Antigenicity?● Storage?● Platelet function?● Wastage?

Nope. It’s coming. Surgeons win!

This IS Blood!

Questions?