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