Damage Control

Resuscitation

Jason R Pickett MD FACEP

Wright State University

Dept of Emergency Medicine

Disclosures

bull Nada

Outline

bull Fluid choices for resuscitation

bull Blood use

bull TXA and othershellip

bull TEG

bull REBOA

We are victims of our own

history

bull There is a fine line between a groove and a rut

What kills trauma

patients

What kills trauma

patients

bull Hypothermia

bull 1deg makes a difference

bull Coagulopathy

bull 25-38 arrive coagulopathic

bull 75 who require MTP

bull Acidosis

bull Respiratory failure only kills 6

DEATH

ACIDOSIS

COAGULOPATHY

HYPO-THERMIA

Damage Control

bull Fire suppression

bull Control flooding

bull Maintain mission

capability

bull Achieve hemostasis

bull Maintain perfusion

bull Restore physiology

Traditional trauma

resuscitation

bull ldquoStart 2 large bore IVs and give up to 2L of crystalloidrdquo

bull -ATLS Manual 9th ed

bull Traditional isotonic crystalloids NS LR

bull Keep SBP gt90

bull Whatrsquos normal about Normal Saline

Solution Na Cl K Ca Mg Lact Acet Gluc

Dex

pH Osm

Plasma 144 107 5 5 15 74 290

09NaCl

ldquonormal salinerdquo

154 154 54 308

Lactated Ringers 130 109 4 3 28 65 273

Normosol 140 98 5 3 27 23 74 295

Plasmalyte A 140 98 5 3 27 23 74 294

Plasmalyte 148 140 98 5 3 27 23 55 294

Hextend 143 124 3 5 09 28 59 307

Hespan 154 154 59 309

Crystalloids in

resuscitation

bull Higher mortality with higher crystalloid volumes in

patients receiving massive transfusion Higher rates of

renal failure too

bull More fluid

bull Volumes gt 15 L of crystalloid = higher mortality

bull Increased ALI ARDS MOSF ICU and hospital LOS

bull Crystalloidblood ratio gt 15L1u associated with higher

mortality and morbidity

Permissive Hypotension

bull Cannon W Fraser J Cowell E The Preventative Treatment of Wound Shock JAMA 1918618-621

bull Poor outcomes with IV fluid resuscitation

bull Forgotten until the 1980s

bull Bickell WH Wall MH Pepe PE Martin RR Ginger VF Allen MK Mattox KL Immediate versus delayed fluid resuscitation for Hypotensive patients with penetrating torso injuries N Engl J Med 1994 Oct 27 3311105-9

bull Maintain SBP 90 mmHg

bull Not good for CNS injuries- linear relationship

Colloids in resuscitation

bull Expensive (20x)

bull No benefit

bull Possible harm death AKI

bull HOWEVER trauma patient cohorts small

bull ldquoThe paper reviewed the use of a variety of hetastarches in a variety of volumes for a variety of indications This study was clearly not designed to answer the question about the risksbenefits of Hextend used in a hypotensive resuscitation strategy for combat casualties when blood products are not available ndash and clearly does not provide that answerrdquo - CoTCCC

Blood Ratios

bull The old LOTS of pRBCs = oxygen carrying capacity

bull The now 111 ratio

bull Replace coagulation factorsplatelets

Blood

bull O- for females at or below CBA

bull O+ for everyone else

bull FFP AB is universal donor

bull A is the next safest

Who Needs Massive

Transfusion

bull Systolic BP lt110

bull HRgt 105

bull Hct lt 32

bull pH lt 725

bull 3 of the 4 70 likelihood

bull 44 85 likelihood

bull INR gt 14 (5x mortality)

bull StO2 lt 75

Who Needs Massive

Transfusion

bull Uncontrolled truncal axillary neck or groin bleeding

bull Uncontrolled bleeding secondary to massive soft tissue

injuries

bull Proximal amputation or mangled extremity

bull Clinical signs of coagulopathy

bull Severe hypothermia with blood loss

Which should we give

first

bull We have decent oxygen carrying capacity when anemic

bull Plasma first transfusion may be better

bull Fix the coagulopathy hypothermia acidosis

bull Prehospital freeze dried plasma (FDP)

bull Being studied by US military

bull Used by our European colleagues

bull not FDA approved in the US currently

Fibrinogen

bull Fresh whole blood 1000 mg of fibrinogen

bull FFP 400 mg

bull Platelets 80 mg

bull Cryoprecipitate 2500 mg

bull Transfusion with high ratios of fibrinogen to RBCs have

shown survival benefit

Fresh Whole Blood

Blood

bull Fresh whole blood AT LEAST equivalent to components

bull May improve survival

bull Restricted fluid resuscitation (lt1500 mL crystalloid) OR

of death 069

bull DCR Less fluid (5 vs 14 L) less pRBCs (7 u vs 13 u)

less ldquolethal triadrdquo (46 vs 80) survival OR 25

TCCC Order of preference

for fluid resuscitation

bull Fresh whole blood

bull PRBCsFFPPlatelets in 111 ratio

bull PRBCsFFP in 11 ratio

bull PRBCs or FFP

bull Plasmalyte Normosol

bull Lactated Ringers

bull Not recommended Normal Saline

Tranexamic Acid

bull Antithrombolytic

bull ldquoHyperfibrinolysis of traumardquo

bull 1g over 10 min

bull Giving it faster can cause hypotension

bull May give up to 5g (studied up to 250mgkg)

bull Re-dose if hemorrhage is ongoing

Tranexamic Acid

bull CRASH-2 bull Given across a wide spectrum of trauma patients in 40 countries

bull ARR 15

bull Poorly controlled only half went to OR

bull MATTERs bull 17 vs 239 mortality

bull Benefit greatest in those getting MTP

bull MATTERs II bull TXA vs Cryo vs TXA+Cryo

bull 116 vs 236 mortality

bull Best benefit lt1h after injury

bull Some benefit lt3h after injury

bull Possible harm gt3h after injury

Tranexamic Acid

bull CRASH-2 TBI

bull Basically a wash

bull Cole Davenport Brohi TXA did not affect mortality in

overall or non-shock cohorts

bull MVA showed OR of MOF 027 and death 016

bull Valle Allen Higher mortality with TXA if needing gt2L

PRBCs

bull Given 97 min after ADMISSION and after transfusion

Factor VIIa

bull No studies showing mortality benefit

bull Studies showing decreased blood loss

bull $45000dose

bull May consider if still bleeding after TXA

Metabolic acidosis

bull Keep pH above 72

bull Administer THAM (Tromethamine solution) or sodium

bicarbonate to maintain pH

bull Weight in kg x base deficit x 11 = volume of THAM

solution to give (18g500mL)

bull Weight in kg x base deficit x 02 = volume of sodium

bicarb solution to give

Calcium

bull Calcium used up in clots

bull Calcium gobbled up by citrate in stored blood

bull Maintain ionized iCa gt 10 (run on ABG machine)

bull 1g Ca Gluconate for every 4 u FFP

Storage lesions

bull Stored blood is acidic

bull Calcium is chelated by preservatives

bull Platelets decline in function

Thromboelastography

(TEG)

bull Gives a better picture of coagulation status

bull Measures time to initiate clot

bull Speed of formation

bull Strength of clot

bull Fibrinolysis

bull Can help guide transfusion therapy

bull Better outcomes at gt10u PRBCs

bull Fewer units of blood

TEG

TEG Value Transfuse

TEG-ACT gt 140 FFP

R time gt 10 FFP

K time gt 3 Cryo

A angle Cry +- Platelets

MA lt 50 Platelets

LY30 gt3 TXA

REBOA

bull Resuscitative Endovascular Balloon Occlusion of the

Aorta

ER REBOA

Bottom Line

bull Keep them WARM

bull Little to no crystalloid

bull Hypotension is bad for brain injuries

bull Think about MT early

bull 111 ratio

bull Give TXA early

bull Calcium

bull Fix acidosis

bull Balogh Z McKinley BA Cocanour CS Kozar RA Valdivia A Sailors RM Moore FA Supra-normal trauma resuscitation causes more cases of abdominal compartment syndrome Arch Surg 138637-643 2003

bull Duchesne JC Heaney J Guidry C McSwain N Jr Meade P Cohen M Schreiber M Inaba K Skiada D Demetriades D Holcomb J Wade C Cotton B Diluting the benefits of hemostatic resuscitation A multi-institutional analysis J Trauma Acute Care Surg 2013 Jul75(1)76-82 doi 101097TA0b013e3182987df3

bull Guidry C Gleeson E Simms ER Stuke L Meade P McSwain NE Jr Duchesne JC Initial assessment on the impact of crystalloids versus colloids during damage control resuscitation J Surg Res 2013 Jun 15 pii S0022-4804(13)00568-4 doi 101016jjss201305086 [Epub ahead of print]

bull Perel P Roberts I Ker K Colloids versus crystalloids for fluid resuscitation in critically ill patients Cochrane Database Syst Rev 2013 Feb 282CD000567 doi 10100214651858CD000567pub6

bull Zarychanski R Abou-Setta AM Turgeon AF et al Association of Hydroxyethyl Starch Administration With Mortality and Acute Kidney Injury in Critically Ill Patients Requiring Volume Resuscitation A Systematic Review and Meta-analysis JAMA 2013309(7)678-688 doi101001jama2013430

bull Bulger EM May S Kerby JD Emerson S Stiell IG Schreiber MA Brasel KJ Tisherman SA Coimbra R Rizoli S Minei JP Hata JS Sopko G Evans DC Hoyt DB ROC investigators Out-of-hospital hypertonic resuscitation after traumatic hypovolemic shock a randomized placebo controlled trial Ann Surg 2011 Mar253(3)431-41 doi 101097SLA0b013e3181fcdb22

bull Vassar MJ Fischer RP OBrien PE Bachulis BL Chambers JA Hoyt DB Holcroft JW A multicenter trial for resuscitation of injured patients with 75 sodium chloride The effect of added dextran 70 The Multicenter Group for the Study of Hypertonic Saline in Trauma Patients Arch Surg 1993 Sep128(9)1003-11 discussion 1011-3

bull Cooper DJ Myles PS McDermott FT Murray LJ Laidlaw J Cooper G Tremayne AB Bernard SS Ponsford J HTS Study Investigators Prehospital hypertonic saline resuscitation of patients with hypotension and severe traumatic brain injury a randomized controlled trial JAMA 2004 Mar 17291(11)1350-7

bull Duke MD Guidry C Guice J Stuke L Marr AB Hunt JP Meade P McSwain NE Jr Duchesne JC Restrictive fluid resuscitation in combination with damage control resuscitation time for adaptation J Trauma Acute Care Surg 2012 Sep73(3)674-8 doi 101097TA0b013e318265ce1f

bull Pidcoke HF Aden JK Mora AG Borgman MA Spinella PC Dubick MA Blackbourne LH Cap AP Ten-year analysis of transfusion in Operation Iraqi Freedom and Operation Enduring Freedom increased plasma and platelet use correlates with improved survival J Trauma Acute Care Surg 2012 Dec73(6 Suppl 5)S445-52 doi 101097TA0b013e3182754796

bull Morrison CA Carrick MM Norman MA Scott BG Welsh FJ Tsai P Liscum KR Wall MJ Jr Mattox KL Hypotensive resuscitation strategy reduces transfusion requirements and severe postoperative coagulopathy in trauma patients with hemorrhagic shock preliminary results of a randomized controlled trial J Trauma 2011 Mar70(3)652-63 doi 101097TA0b013e31820e77ea

bull Ley EJ Clond MA Srour MK Barnajian M Mirocha J Margulies DR Salim A Emergency department crystalloid resuscitation of 15 L or more is associated with increased mortality in elderly and nonelderly trauma patients J Trauma 2011 Feb70(2)398-400 doi 101097TA0b013e318208f99b

bull Kasotakis G Sideris A Yang Y de Moya M Alam H King DR Tompkins R Velmahos G Inflammation and Host Response to Injury Investigators Aggressive early crystalloid resuscitation adversely affects outcomes in adult blunt trauma patients an analysis of the Glue Grant database J Trauma Acute Care Surg 2013 May74(5)1215-21 discussion 1221-2 doi 101097TA0b013e3182826e13

bull Neal MD Hoffman MK Cuschieri J Minei JP Maier RV Harbrecht BG Billiar TR Peitzman AB Moore EE Cohen MJ Sperry JL Crystalloid to packed red blood cell transfusion ratio in the massively transfused patient when a little goes a long way J Trauma Acute Care Surg 2012 Apr72(4)892-8 doi 101097TA0b013e31823d84a7

bull Niles SE McLaughlin DF Perkins JG et al Increased mortality associated with the early coagulopathy of trauma in combat casualties J Trauma 2008641459-63

bull Brohi K Singh J Heron M Coats T Acute traumatic coagulopathy J Trauma 2003541127-30

bull Cotton BA Gunter OL Isbell J et al Damage control hematology the impact of a trauma exsanguination protocol on survival and blood product utilization J Trauma 2008641177-82

bull Keneally RJ1 Parsons AM1 Willett PB1 Warm fresh whole blood and thoracic traumain iraq and afghanistan J Emerg Trauma Shock 2015 Jan-Mar8(1)21-5

bull Spinella PC1 Perkins JG Grathwohl KW Beekley AC Holcomb JB Warm fresh whole blood is independently associated with improved survival for patients with combat-related traumatic injuries J Trauma 2009 Apr66(4 Suppl)S69-76

bull Wafaisade A1 Lefering R2 Bouillon B3 Boumlhmer AB4 Gaumlszligler M5 Ruppert M5 TraumaRegister DGU Prehospital administration of tranexamic acid in trauma patients Crit Care 2016 May 1220(1)143

bull Ausset S1 Glassberg E Nadler R Sunde G Cap AP Hoffmann C Plang S Sailliol A Tranexamic acid as part of remote damage-control resuscitation in the prehospital setting A critical appraisal of the medical literature and available alternatives J Trauma Acute Care Surg 2015 Jun78(6 Suppl 1)S70-5

bull CRASH-2 trial collaborators Shakur H Roberts I Bautista R Caballero J Coats T Dewan Y El-Sayed H Gogichaishvili T Gupta S Herrera J Hunt B Iribhogbe P Izurieta M Khamis H Komolafe E Marrero MA Mejiacutea-Mantilla J Miranda J Morales C Olaomi O Olldashi F Perel P Peto R Ramana PV Ravi RR Yutthakasemsunt S Effects of tranexamic acid on death vascular occlusive events and blood transfusion in trauma patients with significant haemorrhage (CRASH-2) a randomised placebo-controlled trial Lancet 2010 Jul 3376(9734)23-32

bull Morrison JJ1 Dubose JJ Rasmussen TE Midwinter MJ Military Application of Tranexamic Acid in Trauma Emergency Resuscitation (MATTERs) Study Arch Surg 2012 Feb147(2)113-9

bull Morrison JJ1 Ross JD Dubose JJ Jansen JO Midwinter MJ Rasmussen TE Association of cryoprecipitate and tranexamic acid with improved survival following wartime injury findings from the MATTERs II Study JAMA Surg 2013 Mar148(3)218-25

Disclosures

bull Nada

Outline

bull Fluid choices for resuscitation

bull Blood use

bull TXA and othershellip

bull TEG

bull REBOA

We are victims of our own

history

bull There is a fine line between a groove and a rut

What kills trauma

patients

What kills trauma

patients

bull Hypothermia

bull 1deg makes a difference

bull Coagulopathy

bull 25-38 arrive coagulopathic

bull 75 who require MTP

bull Acidosis

bull Respiratory failure only kills 6

DEATH

ACIDOSIS

COAGULOPATHY

HYPO-THERMIA

Damage Control

bull Fire suppression

bull Control flooding

bull Maintain mission

capability

bull Achieve hemostasis

bull Maintain perfusion

bull Restore physiology

Traditional trauma

resuscitation

bull ldquoStart 2 large bore IVs and give up to 2L of crystalloidrdquo

bull -ATLS Manual 9th ed

bull Traditional isotonic crystalloids NS LR

bull Keep SBP gt90

bull Whatrsquos normal about Normal Saline

Solution Na Cl K Ca Mg Lact Acet Gluc

Dex

pH Osm

Plasma 144 107 5 5 15 74 290

09NaCl

ldquonormal salinerdquo

154 154 54 308

Lactated Ringers 130 109 4 3 28 65 273

Normosol 140 98 5 3 27 23 74 295

Plasmalyte A 140 98 5 3 27 23 74 294

Plasmalyte 148 140 98 5 3 27 23 55 294

Hextend 143 124 3 5 09 28 59 307

Hespan 154 154 59 309

Crystalloids in

resuscitation

bull Higher mortality with higher crystalloid volumes in

patients receiving massive transfusion Higher rates of

renal failure too

bull More fluid

bull Volumes gt 15 L of crystalloid = higher mortality

bull Increased ALI ARDS MOSF ICU and hospital LOS

bull Crystalloidblood ratio gt 15L1u associated with higher

mortality and morbidity

Permissive Hypotension

bull Cannon W Fraser J Cowell E The Preventative Treatment of Wound Shock JAMA 1918618-621

bull Poor outcomes with IV fluid resuscitation

bull Forgotten until the 1980s

bull Bickell WH Wall MH Pepe PE Martin RR Ginger VF Allen MK Mattox KL Immediate versus delayed fluid resuscitation for Hypotensive patients with penetrating torso injuries N Engl J Med 1994 Oct 27 3311105-9

bull Maintain SBP 90 mmHg

bull Not good for CNS injuries- linear relationship

Colloids in resuscitation

bull Expensive (20x)

bull No benefit

bull Possible harm death AKI

bull HOWEVER trauma patient cohorts small

bull ldquoThe paper reviewed the use of a variety of hetastarches in a variety of volumes for a variety of indications This study was clearly not designed to answer the question about the risksbenefits of Hextend used in a hypotensive resuscitation strategy for combat casualties when blood products are not available ndash and clearly does not provide that answerrdquo - CoTCCC

Blood Ratios

bull The old LOTS of pRBCs = oxygen carrying capacity

bull The now 111 ratio

bull Replace coagulation factorsplatelets

Blood

bull O- for females at or below CBA

bull O+ for everyone else

bull FFP AB is universal donor

bull A is the next safest

Who Needs Massive

Transfusion

bull Systolic BP lt110

bull HRgt 105

bull Hct lt 32

bull pH lt 725

bull 3 of the 4 70 likelihood

bull 44 85 likelihood

bull INR gt 14 (5x mortality)

bull StO2 lt 75

Who Needs Massive

Transfusion

bull Uncontrolled truncal axillary neck or groin bleeding

bull Uncontrolled bleeding secondary to massive soft tissue

injuries

bull Proximal amputation or mangled extremity

bull Clinical signs of coagulopathy

bull Severe hypothermia with blood loss

Which should we give

first

bull We have decent oxygen carrying capacity when anemic

bull Plasma first transfusion may be better

bull Fix the coagulopathy hypothermia acidosis

bull Prehospital freeze dried plasma (FDP)

bull Being studied by US military

bull Used by our European colleagues

bull not FDA approved in the US currently

Fibrinogen

bull Fresh whole blood 1000 mg of fibrinogen

bull FFP 400 mg

bull Platelets 80 mg

bull Cryoprecipitate 2500 mg

bull Transfusion with high ratios of fibrinogen to RBCs have

shown survival benefit

Fresh Whole Blood

Blood

bull Fresh whole blood AT LEAST equivalent to components

bull May improve survival

bull Restricted fluid resuscitation (lt1500 mL crystalloid) OR

of death 069

bull DCR Less fluid (5 vs 14 L) less pRBCs (7 u vs 13 u)

less ldquolethal triadrdquo (46 vs 80) survival OR 25

TCCC Order of preference

for fluid resuscitation

bull Fresh whole blood

bull PRBCsFFPPlatelets in 111 ratio

bull PRBCsFFP in 11 ratio

bull PRBCs or FFP

bull Plasmalyte Normosol

bull Lactated Ringers

bull Not recommended Normal Saline

Tranexamic Acid

bull Antithrombolytic

bull ldquoHyperfibrinolysis of traumardquo

bull 1g over 10 min

bull Giving it faster can cause hypotension

bull May give up to 5g (studied up to 250mgkg)

bull Re-dose if hemorrhage is ongoing

Tranexamic Acid

bull CRASH-2 bull Given across a wide spectrum of trauma patients in 40 countries

bull ARR 15

bull Poorly controlled only half went to OR

bull MATTERs bull 17 vs 239 mortality

bull Benefit greatest in those getting MTP

bull MATTERs II bull TXA vs Cryo vs TXA+Cryo

bull 116 vs 236 mortality

bull Best benefit lt1h after injury

bull Some benefit lt3h after injury

bull Possible harm gt3h after injury

Tranexamic Acid

bull CRASH-2 TBI

bull Basically a wash

bull Cole Davenport Brohi TXA did not affect mortality in

overall or non-shock cohorts

bull MVA showed OR of MOF 027 and death 016

bull Valle Allen Higher mortality with TXA if needing gt2L

PRBCs

bull Given 97 min after ADMISSION and after transfusion

Factor VIIa

bull No studies showing mortality benefit

bull Studies showing decreased blood loss

bull $45000dose

bull May consider if still bleeding after TXA

Metabolic acidosis

bull Keep pH above 72

bull Administer THAM (Tromethamine solution) or sodium

bicarbonate to maintain pH

bull Weight in kg x base deficit x 11 = volume of THAM

solution to give (18g500mL)

bull Weight in kg x base deficit x 02 = volume of sodium

bicarb solution to give

Calcium

bull Calcium used up in clots

bull Calcium gobbled up by citrate in stored blood

bull Maintain ionized iCa gt 10 (run on ABG machine)

bull 1g Ca Gluconate for every 4 u FFP

Storage lesions

bull Stored blood is acidic

bull Calcium is chelated by preservatives

bull Platelets decline in function

Thromboelastography

(TEG)

bull Gives a better picture of coagulation status

bull Measures time to initiate clot

bull Speed of formation

bull Strength of clot

bull Fibrinolysis

bull Can help guide transfusion therapy

bull Better outcomes at gt10u PRBCs

bull Fewer units of blood

TEG

TEG Value Transfuse

TEG-ACT gt 140 FFP

R time gt 10 FFP

K time gt 3 Cryo

A angle Cry +- Platelets

MA lt 50 Platelets

LY30 gt3 TXA

REBOA

bull Resuscitative Endovascular Balloon Occlusion of the

Aorta

ER REBOA

Bottom Line

bull Keep them WARM

bull Little to no crystalloid

bull Hypotension is bad for brain injuries

bull Think about MT early

bull 111 ratio

bull Give TXA early

bull Calcium

bull Fix acidosis

bull Balogh Z McKinley BA Cocanour CS Kozar RA Valdivia A Sailors RM Moore FA Supra-normal trauma resuscitation causes more cases of abdominal compartment syndrome Arch Surg 138637-643 2003

bull Duchesne JC Heaney J Guidry C McSwain N Jr Meade P Cohen M Schreiber M Inaba K Skiada D Demetriades D Holcomb J Wade C Cotton B Diluting the benefits of hemostatic resuscitation A multi-institutional analysis J Trauma Acute Care Surg 2013 Jul75(1)76-82 doi 101097TA0b013e3182987df3

bull Guidry C Gleeson E Simms ER Stuke L Meade P McSwain NE Jr Duchesne JC Initial assessment on the impact of crystalloids versus colloids during damage control resuscitation J Surg Res 2013 Jun 15 pii S0022-4804(13)00568-4 doi 101016jjss201305086 [Epub ahead of print]

bull Perel P Roberts I Ker K Colloids versus crystalloids for fluid resuscitation in critically ill patients Cochrane Database Syst Rev 2013 Feb 282CD000567 doi 10100214651858CD000567pub6

bull Zarychanski R Abou-Setta AM Turgeon AF et al Association of Hydroxyethyl Starch Administration With Mortality and Acute Kidney Injury in Critically Ill Patients Requiring Volume Resuscitation A Systematic Review and Meta-analysis JAMA 2013309(7)678-688 doi101001jama2013430

bull Bulger EM May S Kerby JD Emerson S Stiell IG Schreiber MA Brasel KJ Tisherman SA Coimbra R Rizoli S Minei JP Hata JS Sopko G Evans DC Hoyt DB ROC investigators Out-of-hospital hypertonic resuscitation after traumatic hypovolemic shock a randomized placebo controlled trial Ann Surg 2011 Mar253(3)431-41 doi 101097SLA0b013e3181fcdb22

bull Vassar MJ Fischer RP OBrien PE Bachulis BL Chambers JA Hoyt DB Holcroft JW A multicenter trial for resuscitation of injured patients with 75 sodium chloride The effect of added dextran 70 The Multicenter Group for the Study of Hypertonic Saline in Trauma Patients Arch Surg 1993 Sep128(9)1003-11 discussion 1011-3

bull Cooper DJ Myles PS McDermott FT Murray LJ Laidlaw J Cooper G Tremayne AB Bernard SS Ponsford J HTS Study Investigators Prehospital hypertonic saline resuscitation of patients with hypotension and severe traumatic brain injury a randomized controlled trial JAMA 2004 Mar 17291(11)1350-7

bull Duke MD Guidry C Guice J Stuke L Marr AB Hunt JP Meade P McSwain NE Jr Duchesne JC Restrictive fluid resuscitation in combination with damage control resuscitation time for adaptation J Trauma Acute Care Surg 2012 Sep73(3)674-8 doi 101097TA0b013e318265ce1f

bull Pidcoke HF Aden JK Mora AG Borgman MA Spinella PC Dubick MA Blackbourne LH Cap AP Ten-year analysis of transfusion in Operation Iraqi Freedom and Operation Enduring Freedom increased plasma and platelet use correlates with improved survival J Trauma Acute Care Surg 2012 Dec73(6 Suppl 5)S445-52 doi 101097TA0b013e3182754796

bull Morrison CA Carrick MM Norman MA Scott BG Welsh FJ Tsai P Liscum KR Wall MJ Jr Mattox KL Hypotensive resuscitation strategy reduces transfusion requirements and severe postoperative coagulopathy in trauma patients with hemorrhagic shock preliminary results of a randomized controlled trial J Trauma 2011 Mar70(3)652-63 doi 101097TA0b013e31820e77ea

bull Ley EJ Clond MA Srour MK Barnajian M Mirocha J Margulies DR Salim A Emergency department crystalloid resuscitation of 15 L or more is associated with increased mortality in elderly and nonelderly trauma patients J Trauma 2011 Feb70(2)398-400 doi 101097TA0b013e318208f99b

bull Kasotakis G Sideris A Yang Y de Moya M Alam H King DR Tompkins R Velmahos G Inflammation and Host Response to Injury Investigators Aggressive early crystalloid resuscitation adversely affects outcomes in adult blunt trauma patients an analysis of the Glue Grant database J Trauma Acute Care Surg 2013 May74(5)1215-21 discussion 1221-2 doi 101097TA0b013e3182826e13

bull Neal MD Hoffman MK Cuschieri J Minei JP Maier RV Harbrecht BG Billiar TR Peitzman AB Moore EE Cohen MJ Sperry JL Crystalloid to packed red blood cell transfusion ratio in the massively transfused patient when a little goes a long way J Trauma Acute Care Surg 2012 Apr72(4)892-8 doi 101097TA0b013e31823d84a7

bull Niles SE McLaughlin DF Perkins JG et al Increased mortality associated with the early coagulopathy of trauma in combat casualties J Trauma 2008641459-63

bull Brohi K Singh J Heron M Coats T Acute traumatic coagulopathy J Trauma 2003541127-30

bull Cotton BA Gunter OL Isbell J et al Damage control hematology the impact of a trauma exsanguination protocol on survival and blood product utilization J Trauma 2008641177-82

bull Keneally RJ1 Parsons AM1 Willett PB1 Warm fresh whole blood and thoracic traumain iraq and afghanistan J Emerg Trauma Shock 2015 Jan-Mar8(1)21-5

bull Spinella PC1 Perkins JG Grathwohl KW Beekley AC Holcomb JB Warm fresh whole blood is independently associated with improved survival for patients with combat-related traumatic injuries J Trauma 2009 Apr66(4 Suppl)S69-76

bull Wafaisade A1 Lefering R2 Bouillon B3 Boumlhmer AB4 Gaumlszligler M5 Ruppert M5 TraumaRegister DGU Prehospital administration of tranexamic acid in trauma patients Crit Care 2016 May 1220(1)143

bull Ausset S1 Glassberg E Nadler R Sunde G Cap AP Hoffmann C Plang S Sailliol A Tranexamic acid as part of remote damage-control resuscitation in the prehospital setting A critical appraisal of the medical literature and available alternatives J Trauma Acute Care Surg 2015 Jun78(6 Suppl 1)S70-5

bull CRASH-2 trial collaborators Shakur H Roberts I Bautista R Caballero J Coats T Dewan Y El-Sayed H Gogichaishvili T Gupta S Herrera J Hunt B Iribhogbe P Izurieta M Khamis H Komolafe E Marrero MA Mejiacutea-Mantilla J Miranda J Morales C Olaomi O Olldashi F Perel P Peto R Ramana PV Ravi RR Yutthakasemsunt S Effects of tranexamic acid on death vascular occlusive events and blood transfusion in trauma patients with significant haemorrhage (CRASH-2) a randomised placebo-controlled trial Lancet 2010 Jul 3376(9734)23-32

bull Morrison JJ1 Dubose JJ Rasmussen TE Midwinter MJ Military Application of Tranexamic Acid in Trauma Emergency Resuscitation (MATTERs) Study Arch Surg 2012 Feb147(2)113-9

bull Morrison JJ1 Ross JD Dubose JJ Jansen JO Midwinter MJ Rasmussen TE Association of cryoprecipitate and tranexamic acid with improved survival following wartime injury findings from the MATTERs II Study JAMA Surg 2013 Mar148(3)218-25

Outline

bull Fluid choices for resuscitation

bull Blood use

bull TXA and othershellip

bull TEG

bull REBOA

We are victims of our own

history

bull There is a fine line between a groove and a rut

What kills trauma

patients

What kills trauma

patients

bull Hypothermia

bull 1deg makes a difference

bull Coagulopathy

bull 25-38 arrive coagulopathic

bull 75 who require MTP

bull Acidosis

bull Respiratory failure only kills 6

DEATH

ACIDOSIS

COAGULOPATHY

HYPO-THERMIA

Damage Control

bull Fire suppression

bull Control flooding

bull Maintain mission

capability

bull Achieve hemostasis

bull Maintain perfusion

bull Restore physiology

Traditional trauma

resuscitation

bull ldquoStart 2 large bore IVs and give up to 2L of crystalloidrdquo

bull -ATLS Manual 9th ed

bull Traditional isotonic crystalloids NS LR

bull Keep SBP gt90

bull Whatrsquos normal about Normal Saline

Solution Na Cl K Ca Mg Lact Acet Gluc

Dex

pH Osm

Plasma 144 107 5 5 15 74 290

09NaCl

ldquonormal salinerdquo

154 154 54 308

Lactated Ringers 130 109 4 3 28 65 273

Normosol 140 98 5 3 27 23 74 295

Plasmalyte A 140 98 5 3 27 23 74 294

Plasmalyte 148 140 98 5 3 27 23 55 294

Hextend 143 124 3 5 09 28 59 307

Hespan 154 154 59 309

Crystalloids in

resuscitation

bull Higher mortality with higher crystalloid volumes in

patients receiving massive transfusion Higher rates of

renal failure too

bull More fluid

bull Volumes gt 15 L of crystalloid = higher mortality

bull Increased ALI ARDS MOSF ICU and hospital LOS

bull Crystalloidblood ratio gt 15L1u associated with higher

mortality and morbidity

Permissive Hypotension

bull Cannon W Fraser J Cowell E The Preventative Treatment of Wound Shock JAMA 1918618-621

bull Poor outcomes with IV fluid resuscitation

bull Forgotten until the 1980s

bull Bickell WH Wall MH Pepe PE Martin RR Ginger VF Allen MK Mattox KL Immediate versus delayed fluid resuscitation for Hypotensive patients with penetrating torso injuries N Engl J Med 1994 Oct 27 3311105-9

bull Maintain SBP 90 mmHg

bull Not good for CNS injuries- linear relationship

Colloids in resuscitation

bull Expensive (20x)

bull No benefit

bull Possible harm death AKI

bull HOWEVER trauma patient cohorts small

bull ldquoThe paper reviewed the use of a variety of hetastarches in a variety of volumes for a variety of indications This study was clearly not designed to answer the question about the risksbenefits of Hextend used in a hypotensive resuscitation strategy for combat casualties when blood products are not available ndash and clearly does not provide that answerrdquo - CoTCCC

Blood Ratios

bull The old LOTS of pRBCs = oxygen carrying capacity

bull The now 111 ratio

bull Replace coagulation factorsplatelets

Blood

bull O- for females at or below CBA

bull O+ for everyone else

bull FFP AB is universal donor

bull A is the next safest

Who Needs Massive

Transfusion

bull Systolic BP lt110

bull HRgt 105

bull Hct lt 32

bull pH lt 725

bull 3 of the 4 70 likelihood

bull 44 85 likelihood

bull INR gt 14 (5x mortality)

bull StO2 lt 75

Who Needs Massive

Transfusion

bull Uncontrolled truncal axillary neck or groin bleeding

bull Uncontrolled bleeding secondary to massive soft tissue

injuries

bull Proximal amputation or mangled extremity

bull Clinical signs of coagulopathy

bull Severe hypothermia with blood loss

Which should we give

first

bull We have decent oxygen carrying capacity when anemic

bull Plasma first transfusion may be better

bull Fix the coagulopathy hypothermia acidosis

bull Prehospital freeze dried plasma (FDP)

bull Being studied by US military

bull Used by our European colleagues

bull not FDA approved in the US currently

Fibrinogen

bull Fresh whole blood 1000 mg of fibrinogen

bull FFP 400 mg

bull Platelets 80 mg

bull Cryoprecipitate 2500 mg

bull Transfusion with high ratios of fibrinogen to RBCs have

shown survival benefit

Fresh Whole Blood

Blood

bull Fresh whole blood AT LEAST equivalent to components

bull May improve survival

bull Restricted fluid resuscitation (lt1500 mL crystalloid) OR

of death 069

bull DCR Less fluid (5 vs 14 L) less pRBCs (7 u vs 13 u)

less ldquolethal triadrdquo (46 vs 80) survival OR 25

TCCC Order of preference

for fluid resuscitation

bull Fresh whole blood

bull PRBCsFFPPlatelets in 111 ratio

bull PRBCsFFP in 11 ratio

bull PRBCs or FFP

bull Plasmalyte Normosol

bull Lactated Ringers

bull Not recommended Normal Saline

Tranexamic Acid

bull Antithrombolytic

bull ldquoHyperfibrinolysis of traumardquo

bull 1g over 10 min

bull Giving it faster can cause hypotension

bull May give up to 5g (studied up to 250mgkg)

bull Re-dose if hemorrhage is ongoing

Tranexamic Acid

bull CRASH-2 bull Given across a wide spectrum of trauma patients in 40 countries

bull ARR 15

bull Poorly controlled only half went to OR

bull MATTERs bull 17 vs 239 mortality

bull Benefit greatest in those getting MTP

bull MATTERs II bull TXA vs Cryo vs TXA+Cryo

bull 116 vs 236 mortality

bull Best benefit lt1h after injury

bull Some benefit lt3h after injury

bull Possible harm gt3h after injury

Tranexamic Acid

bull CRASH-2 TBI

bull Basically a wash

bull Cole Davenport Brohi TXA did not affect mortality in

overall or non-shock cohorts

bull MVA showed OR of MOF 027 and death 016

bull Valle Allen Higher mortality with TXA if needing gt2L

PRBCs

bull Given 97 min after ADMISSION and after transfusion

Factor VIIa

bull No studies showing mortality benefit

bull Studies showing decreased blood loss

bull $45000dose

bull May consider if still bleeding after TXA

Metabolic acidosis

bull Keep pH above 72

bull Administer THAM (Tromethamine solution) or sodium

bicarbonate to maintain pH

bull Weight in kg x base deficit x 11 = volume of THAM

solution to give (18g500mL)

bull Weight in kg x base deficit x 02 = volume of sodium

bicarb solution to give

Calcium

bull Calcium used up in clots

bull Calcium gobbled up by citrate in stored blood

bull Maintain ionized iCa gt 10 (run on ABG machine)

bull 1g Ca Gluconate for every 4 u FFP

Storage lesions

bull Stored blood is acidic

bull Calcium is chelated by preservatives

bull Platelets decline in function

Thromboelastography

(TEG)

bull Gives a better picture of coagulation status

bull Measures time to initiate clot

bull Speed of formation

bull Strength of clot

bull Fibrinolysis

bull Can help guide transfusion therapy

bull Better outcomes at gt10u PRBCs

bull Fewer units of blood

TEG

TEG Value Transfuse

TEG-ACT gt 140 FFP

R time gt 10 FFP

K time gt 3 Cryo

A angle Cry +- Platelets

MA lt 50 Platelets

LY30 gt3 TXA

REBOA

bull Resuscitative Endovascular Balloon Occlusion of the

Aorta

ER REBOA

Bottom Line

bull Keep them WARM

bull Little to no crystalloid

bull Hypotension is bad for brain injuries

bull Think about MT early

bull 111 ratio

bull Give TXA early

bull Calcium

bull Fix acidosis

bull Balogh Z McKinley BA Cocanour CS Kozar RA Valdivia A Sailors RM Moore FA Supra-normal trauma resuscitation causes more cases of abdominal compartment syndrome Arch Surg 138637-643 2003

bull Duchesne JC Heaney J Guidry C McSwain N Jr Meade P Cohen M Schreiber M Inaba K Skiada D Demetriades D Holcomb J Wade C Cotton B Diluting the benefits of hemostatic resuscitation A multi-institutional analysis J Trauma Acute Care Surg 2013 Jul75(1)76-82 doi 101097TA0b013e3182987df3

bull Guidry C Gleeson E Simms ER Stuke L Meade P McSwain NE Jr Duchesne JC Initial assessment on the impact of crystalloids versus colloids during damage control resuscitation J Surg Res 2013 Jun 15 pii S0022-4804(13)00568-4 doi 101016jjss201305086 [Epub ahead of print]

bull Perel P Roberts I Ker K Colloids versus crystalloids for fluid resuscitation in critically ill patients Cochrane Database Syst Rev 2013 Feb 282CD000567 doi 10100214651858CD000567pub6

bull Zarychanski R Abou-Setta AM Turgeon AF et al Association of Hydroxyethyl Starch Administration With Mortality and Acute Kidney Injury in Critically Ill Patients Requiring Volume Resuscitation A Systematic Review and Meta-analysis JAMA 2013309(7)678-688 doi101001jama2013430

bull Bulger EM May S Kerby JD Emerson S Stiell IG Schreiber MA Brasel KJ Tisherman SA Coimbra R Rizoli S Minei JP Hata JS Sopko G Evans DC Hoyt DB ROC investigators Out-of-hospital hypertonic resuscitation after traumatic hypovolemic shock a randomized placebo controlled trial Ann Surg 2011 Mar253(3)431-41 doi 101097SLA0b013e3181fcdb22

bull Vassar MJ Fischer RP OBrien PE Bachulis BL Chambers JA Hoyt DB Holcroft JW A multicenter trial for resuscitation of injured patients with 75 sodium chloride The effect of added dextran 70 The Multicenter Group for the Study of Hypertonic Saline in Trauma Patients Arch Surg 1993 Sep128(9)1003-11 discussion 1011-3

bull Cooper DJ Myles PS McDermott FT Murray LJ Laidlaw J Cooper G Tremayne AB Bernard SS Ponsford J HTS Study Investigators Prehospital hypertonic saline resuscitation of patients with hypotension and severe traumatic brain injury a randomized controlled trial JAMA 2004 Mar 17291(11)1350-7

bull Duke MD Guidry C Guice J Stuke L Marr AB Hunt JP Meade P McSwain NE Jr Duchesne JC Restrictive fluid resuscitation in combination with damage control resuscitation time for adaptation J Trauma Acute Care Surg 2012 Sep73(3)674-8 doi 101097TA0b013e318265ce1f

bull Pidcoke HF Aden JK Mora AG Borgman MA Spinella PC Dubick MA Blackbourne LH Cap AP Ten-year analysis of transfusion in Operation Iraqi Freedom and Operation Enduring Freedom increased plasma and platelet use correlates with improved survival J Trauma Acute Care Surg 2012 Dec73(6 Suppl 5)S445-52 doi 101097TA0b013e3182754796

bull Morrison CA Carrick MM Norman MA Scott BG Welsh FJ Tsai P Liscum KR Wall MJ Jr Mattox KL Hypotensive resuscitation strategy reduces transfusion requirements and severe postoperative coagulopathy in trauma patients with hemorrhagic shock preliminary results of a randomized controlled trial J Trauma 2011 Mar70(3)652-63 doi 101097TA0b013e31820e77ea

bull Ley EJ Clond MA Srour MK Barnajian M Mirocha J Margulies DR Salim A Emergency department crystalloid resuscitation of 15 L or more is associated with increased mortality in elderly and nonelderly trauma patients J Trauma 2011 Feb70(2)398-400 doi 101097TA0b013e318208f99b

bull Kasotakis G Sideris A Yang Y de Moya M Alam H King DR Tompkins R Velmahos G Inflammation and Host Response to Injury Investigators Aggressive early crystalloid resuscitation adversely affects outcomes in adult blunt trauma patients an analysis of the Glue Grant database J Trauma Acute Care Surg 2013 May74(5)1215-21 discussion 1221-2 doi 101097TA0b013e3182826e13

bull Neal MD Hoffman MK Cuschieri J Minei JP Maier RV Harbrecht BG Billiar TR Peitzman AB Moore EE Cohen MJ Sperry JL Crystalloid to packed red blood cell transfusion ratio in the massively transfused patient when a little goes a long way J Trauma Acute Care Surg 2012 Apr72(4)892-8 doi 101097TA0b013e31823d84a7

bull Niles SE McLaughlin DF Perkins JG et al Increased mortality associated with the early coagulopathy of trauma in combat casualties J Trauma 2008641459-63

bull Brohi K Singh J Heron M Coats T Acute traumatic coagulopathy J Trauma 2003541127-30

bull Cotton BA Gunter OL Isbell J et al Damage control hematology the impact of a trauma exsanguination protocol on survival and blood product utilization J Trauma 2008641177-82

bull Keneally RJ1 Parsons AM1 Willett PB1 Warm fresh whole blood and thoracic traumain iraq and afghanistan J Emerg Trauma Shock 2015 Jan-Mar8(1)21-5

bull Spinella PC1 Perkins JG Grathwohl KW Beekley AC Holcomb JB Warm fresh whole blood is independently associated with improved survival for patients with combat-related traumatic injuries J Trauma 2009 Apr66(4 Suppl)S69-76

bull Wafaisade A1 Lefering R2 Bouillon B3 Boumlhmer AB4 Gaumlszligler M5 Ruppert M5 TraumaRegister DGU Prehospital administration of tranexamic acid in trauma patients Crit Care 2016 May 1220(1)143

bull Ausset S1 Glassberg E Nadler R Sunde G Cap AP Hoffmann C Plang S Sailliol A Tranexamic acid as part of remote damage-control resuscitation in the prehospital setting A critical appraisal of the medical literature and available alternatives J Trauma Acute Care Surg 2015 Jun78(6 Suppl 1)S70-5

bull CRASH-2 trial collaborators Shakur H Roberts I Bautista R Caballero J Coats T Dewan Y El-Sayed H Gogichaishvili T Gupta S Herrera J Hunt B Iribhogbe P Izurieta M Khamis H Komolafe E Marrero MA Mejiacutea-Mantilla J Miranda J Morales C Olaomi O Olldashi F Perel P Peto R Ramana PV Ravi RR Yutthakasemsunt S Effects of tranexamic acid on death vascular occlusive events and blood transfusion in trauma patients with significant haemorrhage (CRASH-2) a randomised placebo-controlled trial Lancet 2010 Jul 3376(9734)23-32

bull Morrison JJ1 Dubose JJ Rasmussen TE Midwinter MJ Military Application of Tranexamic Acid in Trauma Emergency Resuscitation (MATTERs) Study Arch Surg 2012 Feb147(2)113-9

bull Morrison JJ1 Ross JD Dubose JJ Jansen JO Midwinter MJ Rasmussen TE Association of cryoprecipitate and tranexamic acid with improved survival following wartime injury findings from the MATTERs II Study JAMA Surg 2013 Mar148(3)218-25

We are victims of our own

history

bull There is a fine line between a groove and a rut

What kills trauma

patients

What kills trauma

patients

bull Hypothermia

bull 1deg makes a difference

bull Coagulopathy

bull 25-38 arrive coagulopathic

bull 75 who require MTP

bull Acidosis

bull Respiratory failure only kills 6

DEATH

ACIDOSIS

COAGULOPATHY

HYPO-THERMIA

Damage Control

bull Fire suppression

bull Control flooding

bull Maintain mission

capability

bull Achieve hemostasis

bull Maintain perfusion

bull Restore physiology

Traditional trauma

resuscitation

bull ldquoStart 2 large bore IVs and give up to 2L of crystalloidrdquo

bull -ATLS Manual 9th ed

bull Traditional isotonic crystalloids NS LR

bull Keep SBP gt90

bull Whatrsquos normal about Normal Saline

Solution Na Cl K Ca Mg Lact Acet Gluc

Dex

pH Osm

Plasma 144 107 5 5 15 74 290

09NaCl

ldquonormal salinerdquo

154 154 54 308

Lactated Ringers 130 109 4 3 28 65 273

Normosol 140 98 5 3 27 23 74 295

Plasmalyte A 140 98 5 3 27 23 74 294

Plasmalyte 148 140 98 5 3 27 23 55 294

Hextend 143 124 3 5 09 28 59 307

Hespan 154 154 59 309

Crystalloids in

resuscitation

bull Higher mortality with higher crystalloid volumes in

patients receiving massive transfusion Higher rates of

renal failure too

bull More fluid

bull Volumes gt 15 L of crystalloid = higher mortality

bull Increased ALI ARDS MOSF ICU and hospital LOS

bull Crystalloidblood ratio gt 15L1u associated with higher

mortality and morbidity

Permissive Hypotension

bull Cannon W Fraser J Cowell E The Preventative Treatment of Wound Shock JAMA 1918618-621

bull Poor outcomes with IV fluid resuscitation

bull Forgotten until the 1980s

bull Bickell WH Wall MH Pepe PE Martin RR Ginger VF Allen MK Mattox KL Immediate versus delayed fluid resuscitation for Hypotensive patients with penetrating torso injuries N Engl J Med 1994 Oct 27 3311105-9

bull Maintain SBP 90 mmHg

bull Not good for CNS injuries- linear relationship

Colloids in resuscitation

bull Expensive (20x)

bull No benefit

bull Possible harm death AKI

bull HOWEVER trauma patient cohorts small

bull ldquoThe paper reviewed the use of a variety of hetastarches in a variety of volumes for a variety of indications This study was clearly not designed to answer the question about the risksbenefits of Hextend used in a hypotensive resuscitation strategy for combat casualties when blood products are not available ndash and clearly does not provide that answerrdquo - CoTCCC

Blood Ratios

bull The old LOTS of pRBCs = oxygen carrying capacity

bull The now 111 ratio

bull Replace coagulation factorsplatelets

Blood

bull O- for females at or below CBA

bull O+ for everyone else

bull FFP AB is universal donor

bull A is the next safest

Who Needs Massive

Transfusion

bull Systolic BP lt110

bull HRgt 105

bull Hct lt 32

bull pH lt 725

bull 3 of the 4 70 likelihood

bull 44 85 likelihood

bull INR gt 14 (5x mortality)

bull StO2 lt 75

Who Needs Massive

Transfusion

bull Uncontrolled truncal axillary neck or groin bleeding

bull Uncontrolled bleeding secondary to massive soft tissue

injuries

bull Proximal amputation or mangled extremity

bull Clinical signs of coagulopathy

bull Severe hypothermia with blood loss

Which should we give

first

bull We have decent oxygen carrying capacity when anemic

bull Plasma first transfusion may be better

bull Fix the coagulopathy hypothermia acidosis

bull Prehospital freeze dried plasma (FDP)

bull Being studied by US military

bull Used by our European colleagues

bull not FDA approved in the US currently

Fibrinogen

bull Fresh whole blood 1000 mg of fibrinogen

bull FFP 400 mg

bull Platelets 80 mg

bull Cryoprecipitate 2500 mg

bull Transfusion with high ratios of fibrinogen to RBCs have

shown survival benefit

Fresh Whole Blood

Blood

bull Fresh whole blood AT LEAST equivalent to components

bull May improve survival

bull Restricted fluid resuscitation (lt1500 mL crystalloid) OR

of death 069

bull DCR Less fluid (5 vs 14 L) less pRBCs (7 u vs 13 u)

less ldquolethal triadrdquo (46 vs 80) survival OR 25

TCCC Order of preference

for fluid resuscitation

bull Fresh whole blood

bull PRBCsFFPPlatelets in 111 ratio

bull PRBCsFFP in 11 ratio

bull PRBCs or FFP

bull Plasmalyte Normosol

bull Lactated Ringers

bull Not recommended Normal Saline

Tranexamic Acid

bull Antithrombolytic

bull ldquoHyperfibrinolysis of traumardquo

bull 1g over 10 min

bull Giving it faster can cause hypotension

bull May give up to 5g (studied up to 250mgkg)

bull Re-dose if hemorrhage is ongoing

Tranexamic Acid

bull CRASH-2 bull Given across a wide spectrum of trauma patients in 40 countries

bull ARR 15

bull Poorly controlled only half went to OR

bull MATTERs bull 17 vs 239 mortality

bull Benefit greatest in those getting MTP

bull MATTERs II bull TXA vs Cryo vs TXA+Cryo

bull 116 vs 236 mortality

bull Best benefit lt1h after injury

bull Some benefit lt3h after injury

bull Possible harm gt3h after injury

Tranexamic Acid

bull CRASH-2 TBI

bull Basically a wash

bull Cole Davenport Brohi TXA did not affect mortality in

overall or non-shock cohorts

bull MVA showed OR of MOF 027 and death 016

bull Valle Allen Higher mortality with TXA if needing gt2L

PRBCs

bull Given 97 min after ADMISSION and after transfusion

Factor VIIa

bull No studies showing mortality benefit

bull Studies showing decreased blood loss

bull $45000dose

bull May consider if still bleeding after TXA

Metabolic acidosis

bull Keep pH above 72

bull Administer THAM (Tromethamine solution) or sodium

bicarbonate to maintain pH

bull Weight in kg x base deficit x 11 = volume of THAM

solution to give (18g500mL)

bull Weight in kg x base deficit x 02 = volume of sodium

bicarb solution to give

Calcium

bull Calcium used up in clots

bull Calcium gobbled up by citrate in stored blood

bull Maintain ionized iCa gt 10 (run on ABG machine)

bull 1g Ca Gluconate for every 4 u FFP

Storage lesions

bull Stored blood is acidic

bull Calcium is chelated by preservatives

bull Platelets decline in function

Thromboelastography

(TEG)

bull Gives a better picture of coagulation status

bull Measures time to initiate clot

bull Speed of formation

bull Strength of clot

bull Fibrinolysis

bull Can help guide transfusion therapy

bull Better outcomes at gt10u PRBCs

bull Fewer units of blood

TEG

TEG Value Transfuse

TEG-ACT gt 140 FFP

R time gt 10 FFP

K time gt 3 Cryo

A angle Cry +- Platelets

MA lt 50 Platelets

LY30 gt3 TXA

REBOA

bull Resuscitative Endovascular Balloon Occlusion of the

Aorta

ER REBOA

Bottom Line

bull Keep them WARM

bull Little to no crystalloid

bull Hypotension is bad for brain injuries

bull Think about MT early

bull 111 ratio

bull Give TXA early

bull Calcium

bull Fix acidosis

bull Balogh Z McKinley BA Cocanour CS Kozar RA Valdivia A Sailors RM Moore FA Supra-normal trauma resuscitation causes more cases of abdominal compartment syndrome Arch Surg 138637-643 2003

bull Duchesne JC Heaney J Guidry C McSwain N Jr Meade P Cohen M Schreiber M Inaba K Skiada D Demetriades D Holcomb J Wade C Cotton B Diluting the benefits of hemostatic resuscitation A multi-institutional analysis J Trauma Acute Care Surg 2013 Jul75(1)76-82 doi 101097TA0b013e3182987df3

bull Guidry C Gleeson E Simms ER Stuke L Meade P McSwain NE Jr Duchesne JC Initial assessment on the impact of crystalloids versus colloids during damage control resuscitation J Surg Res 2013 Jun 15 pii S0022-4804(13)00568-4 doi 101016jjss201305086 [Epub ahead of print]

bull Perel P Roberts I Ker K Colloids versus crystalloids for fluid resuscitation in critically ill patients Cochrane Database Syst Rev 2013 Feb 282CD000567 doi 10100214651858CD000567pub6

bull Zarychanski R Abou-Setta AM Turgeon AF et al Association of Hydroxyethyl Starch Administration With Mortality and Acute Kidney Injury in Critically Ill Patients Requiring Volume Resuscitation A Systematic Review and Meta-analysis JAMA 2013309(7)678-688 doi101001jama2013430

bull Bulger EM May S Kerby JD Emerson S Stiell IG Schreiber MA Brasel KJ Tisherman SA Coimbra R Rizoli S Minei JP Hata JS Sopko G Evans DC Hoyt DB ROC investigators Out-of-hospital hypertonic resuscitation after traumatic hypovolemic shock a randomized placebo controlled trial Ann Surg 2011 Mar253(3)431-41 doi 101097SLA0b013e3181fcdb22

bull Vassar MJ Fischer RP OBrien PE Bachulis BL Chambers JA Hoyt DB Holcroft JW A multicenter trial for resuscitation of injured patients with 75 sodium chloride The effect of added dextran 70 The Multicenter Group for the Study of Hypertonic Saline in Trauma Patients Arch Surg 1993 Sep128(9)1003-11 discussion 1011-3

bull Cooper DJ Myles PS McDermott FT Murray LJ Laidlaw J Cooper G Tremayne AB Bernard SS Ponsford J HTS Study Investigators Prehospital hypertonic saline resuscitation of patients with hypotension and severe traumatic brain injury a randomized controlled trial JAMA 2004 Mar 17291(11)1350-7

bull Duke MD Guidry C Guice J Stuke L Marr AB Hunt JP Meade P McSwain NE Jr Duchesne JC Restrictive fluid resuscitation in combination with damage control resuscitation time for adaptation J Trauma Acute Care Surg 2012 Sep73(3)674-8 doi 101097TA0b013e318265ce1f

bull Pidcoke HF Aden JK Mora AG Borgman MA Spinella PC Dubick MA Blackbourne LH Cap AP Ten-year analysis of transfusion in Operation Iraqi Freedom and Operation Enduring Freedom increased plasma and platelet use correlates with improved survival J Trauma Acute Care Surg 2012 Dec73(6 Suppl 5)S445-52 doi 101097TA0b013e3182754796

bull Morrison CA Carrick MM Norman MA Scott BG Welsh FJ Tsai P Liscum KR Wall MJ Jr Mattox KL Hypotensive resuscitation strategy reduces transfusion requirements and severe postoperative coagulopathy in trauma patients with hemorrhagic shock preliminary results of a randomized controlled trial J Trauma 2011 Mar70(3)652-63 doi 101097TA0b013e31820e77ea

bull Ley EJ Clond MA Srour MK Barnajian M Mirocha J Margulies DR Salim A Emergency department crystalloid resuscitation of 15 L or more is associated with increased mortality in elderly and nonelderly trauma patients J Trauma 2011 Feb70(2)398-400 doi 101097TA0b013e318208f99b

bull Kasotakis G Sideris A Yang Y de Moya M Alam H King DR Tompkins R Velmahos G Inflammation and Host Response to Injury Investigators Aggressive early crystalloid resuscitation adversely affects outcomes in adult blunt trauma patients an analysis of the Glue Grant database J Trauma Acute Care Surg 2013 May74(5)1215-21 discussion 1221-2 doi 101097TA0b013e3182826e13

bull Neal MD Hoffman MK Cuschieri J Minei JP Maier RV Harbrecht BG Billiar TR Peitzman AB Moore EE Cohen MJ Sperry JL Crystalloid to packed red blood cell transfusion ratio in the massively transfused patient when a little goes a long way J Trauma Acute Care Surg 2012 Apr72(4)892-8 doi 101097TA0b013e31823d84a7

bull Niles SE McLaughlin DF Perkins JG et al Increased mortality associated with the early coagulopathy of trauma in combat casualties J Trauma 2008641459-63

bull Brohi K Singh J Heron M Coats T Acute traumatic coagulopathy J Trauma 2003541127-30

bull Cotton BA Gunter OL Isbell J et al Damage control hematology the impact of a trauma exsanguination protocol on survival and blood product utilization J Trauma 2008641177-82

bull Keneally RJ1 Parsons AM1 Willett PB1 Warm fresh whole blood and thoracic traumain iraq and afghanistan J Emerg Trauma Shock 2015 Jan-Mar8(1)21-5

bull Spinella PC1 Perkins JG Grathwohl KW Beekley AC Holcomb JB Warm fresh whole blood is independently associated with improved survival for patients with combat-related traumatic injuries J Trauma 2009 Apr66(4 Suppl)S69-76

bull Wafaisade A1 Lefering R2 Bouillon B3 Boumlhmer AB4 Gaumlszligler M5 Ruppert M5 TraumaRegister DGU Prehospital administration of tranexamic acid in trauma patients Crit Care 2016 May 1220(1)143

bull Ausset S1 Glassberg E Nadler R Sunde G Cap AP Hoffmann C Plang S Sailliol A Tranexamic acid as part of remote damage-control resuscitation in the prehospital setting A critical appraisal of the medical literature and available alternatives J Trauma Acute Care Surg 2015 Jun78(6 Suppl 1)S70-5

bull CRASH-2 trial collaborators Shakur H Roberts I Bautista R Caballero J Coats T Dewan Y El-Sayed H Gogichaishvili T Gupta S Herrera J Hunt B Iribhogbe P Izurieta M Khamis H Komolafe E Marrero MA Mejiacutea-Mantilla J Miranda J Morales C Olaomi O Olldashi F Perel P Peto R Ramana PV Ravi RR Yutthakasemsunt S Effects of tranexamic acid on death vascular occlusive events and blood transfusion in trauma patients with significant haemorrhage (CRASH-2) a randomised placebo-controlled trial Lancet 2010 Jul 3376(9734)23-32

bull Morrison JJ1 Dubose JJ Rasmussen TE Midwinter MJ Military Application of Tranexamic Acid in Trauma Emergency Resuscitation (MATTERs) Study Arch Surg 2012 Feb147(2)113-9

bull Morrison JJ1 Ross JD Dubose JJ Jansen JO Midwinter MJ Rasmussen TE Association of cryoprecipitate and tranexamic acid with improved survival following wartime injury findings from the MATTERs II Study JAMA Surg 2013 Mar148(3)218-25

What kills trauma

patients

What kills trauma

patients

bull Hypothermia

bull 1deg makes a difference

bull Coagulopathy

bull 25-38 arrive coagulopathic

bull 75 who require MTP

bull Acidosis

bull Respiratory failure only kills 6

DEATH

ACIDOSIS

COAGULOPATHY

HYPO-THERMIA

Damage Control

bull Fire suppression

bull Control flooding

bull Maintain mission

capability

bull Achieve hemostasis

bull Maintain perfusion

bull Restore physiology

Traditional trauma

resuscitation

bull ldquoStart 2 large bore IVs and give up to 2L of crystalloidrdquo

bull -ATLS Manual 9th ed

bull Traditional isotonic crystalloids NS LR

bull Keep SBP gt90

bull Whatrsquos normal about Normal Saline

Solution Na Cl K Ca Mg Lact Acet Gluc

Dex

pH Osm

Plasma 144 107 5 5 15 74 290

09NaCl

ldquonormal salinerdquo

154 154 54 308

Lactated Ringers 130 109 4 3 28 65 273

Normosol 140 98 5 3 27 23 74 295

Plasmalyte A 140 98 5 3 27 23 74 294

Plasmalyte 148 140 98 5 3 27 23 55 294

Hextend 143 124 3 5 09 28 59 307

Hespan 154 154 59 309

Crystalloids in

resuscitation

bull Higher mortality with higher crystalloid volumes in

patients receiving massive transfusion Higher rates of

renal failure too

bull More fluid

bull Volumes gt 15 L of crystalloid = higher mortality

bull Increased ALI ARDS MOSF ICU and hospital LOS

bull Crystalloidblood ratio gt 15L1u associated with higher

mortality and morbidity

Permissive Hypotension

bull Cannon W Fraser J Cowell E The Preventative Treatment of Wound Shock JAMA 1918618-621

bull Poor outcomes with IV fluid resuscitation

bull Forgotten until the 1980s

bull Bickell WH Wall MH Pepe PE Martin RR Ginger VF Allen MK Mattox KL Immediate versus delayed fluid resuscitation for Hypotensive patients with penetrating torso injuries N Engl J Med 1994 Oct 27 3311105-9

bull Maintain SBP 90 mmHg

bull Not good for CNS injuries- linear relationship

Colloids in resuscitation

bull Expensive (20x)

bull No benefit

bull Possible harm death AKI

bull HOWEVER trauma patient cohorts small

bull ldquoThe paper reviewed the use of a variety of hetastarches in a variety of volumes for a variety of indications This study was clearly not designed to answer the question about the risksbenefits of Hextend used in a hypotensive resuscitation strategy for combat casualties when blood products are not available ndash and clearly does not provide that answerrdquo - CoTCCC

Blood Ratios

bull The old LOTS of pRBCs = oxygen carrying capacity

bull The now 111 ratio

bull Replace coagulation factorsplatelets

Blood

bull O- for females at or below CBA

bull O+ for everyone else

bull FFP AB is universal donor

bull A is the next safest

Who Needs Massive

Transfusion

bull Systolic BP lt110

bull HRgt 105

bull Hct lt 32

bull pH lt 725

bull 3 of the 4 70 likelihood

bull 44 85 likelihood

bull INR gt 14 (5x mortality)

bull StO2 lt 75

Who Needs Massive

Transfusion

bull Uncontrolled truncal axillary neck or groin bleeding

bull Uncontrolled bleeding secondary to massive soft tissue

injuries

bull Proximal amputation or mangled extremity

bull Clinical signs of coagulopathy

bull Severe hypothermia with blood loss

Which should we give

first

bull We have decent oxygen carrying capacity when anemic

bull Plasma first transfusion may be better

bull Fix the coagulopathy hypothermia acidosis

bull Prehospital freeze dried plasma (FDP)

bull Being studied by US military

bull Used by our European colleagues

bull not FDA approved in the US currently

Fibrinogen

bull Fresh whole blood 1000 mg of fibrinogen

bull FFP 400 mg

bull Platelets 80 mg

bull Cryoprecipitate 2500 mg

bull Transfusion with high ratios of fibrinogen to RBCs have

shown survival benefit

Fresh Whole Blood

Blood

bull Fresh whole blood AT LEAST equivalent to components

bull May improve survival

bull Restricted fluid resuscitation (lt1500 mL crystalloid) OR

of death 069

bull DCR Less fluid (5 vs 14 L) less pRBCs (7 u vs 13 u)

less ldquolethal triadrdquo (46 vs 80) survival OR 25

TCCC Order of preference

for fluid resuscitation

bull Fresh whole blood

bull PRBCsFFPPlatelets in 111 ratio

bull PRBCsFFP in 11 ratio

bull PRBCs or FFP

bull Plasmalyte Normosol

bull Lactated Ringers

bull Not recommended Normal Saline

Tranexamic Acid

bull Antithrombolytic

bull ldquoHyperfibrinolysis of traumardquo

bull 1g over 10 min

bull Giving it faster can cause hypotension

bull May give up to 5g (studied up to 250mgkg)

bull Re-dose if hemorrhage is ongoing

Tranexamic Acid

bull CRASH-2 bull Given across a wide spectrum of trauma patients in 40 countries

bull ARR 15

bull Poorly controlled only half went to OR

bull MATTERs bull 17 vs 239 mortality

bull Benefit greatest in those getting MTP

bull MATTERs II bull TXA vs Cryo vs TXA+Cryo

bull 116 vs 236 mortality

bull Best benefit lt1h after injury

bull Some benefit lt3h after injury

bull Possible harm gt3h after injury

Tranexamic Acid

bull CRASH-2 TBI

bull Basically a wash

bull Cole Davenport Brohi TXA did not affect mortality in

overall or non-shock cohorts

bull MVA showed OR of MOF 027 and death 016

bull Valle Allen Higher mortality with TXA if needing gt2L

PRBCs

bull Given 97 min after ADMISSION and after transfusion

Factor VIIa

bull No studies showing mortality benefit

bull Studies showing decreased blood loss

bull $45000dose

bull May consider if still bleeding after TXA

Metabolic acidosis

bull Keep pH above 72

bull Administer THAM (Tromethamine solution) or sodium

bicarbonate to maintain pH

bull Weight in kg x base deficit x 11 = volume of THAM

solution to give (18g500mL)

bull Weight in kg x base deficit x 02 = volume of sodium

bicarb solution to give

Calcium

bull Calcium used up in clots

bull Calcium gobbled up by citrate in stored blood

bull Maintain ionized iCa gt 10 (run on ABG machine)

bull 1g Ca Gluconate for every 4 u FFP

Storage lesions

bull Stored blood is acidic

bull Calcium is chelated by preservatives

bull Platelets decline in function

Thromboelastography

(TEG)

bull Gives a better picture of coagulation status

bull Measures time to initiate clot

bull Speed of formation

bull Strength of clot

bull Fibrinolysis

bull Can help guide transfusion therapy

bull Better outcomes at gt10u PRBCs

bull Fewer units of blood

TEG

TEG Value Transfuse

TEG-ACT gt 140 FFP

R time gt 10 FFP

K time gt 3 Cryo

A angle Cry +- Platelets

MA lt 50 Platelets

LY30 gt3 TXA

REBOA

bull Resuscitative Endovascular Balloon Occlusion of the

Aorta

ER REBOA

Bottom Line

bull Keep them WARM

bull Little to no crystalloid

bull Hypotension is bad for brain injuries

bull Think about MT early

bull 111 ratio

bull Give TXA early

bull Calcium

bull Fix acidosis

bull Balogh Z McKinley BA Cocanour CS Kozar RA Valdivia A Sailors RM Moore FA Supra-normal trauma resuscitation causes more cases of abdominal compartment syndrome Arch Surg 138637-643 2003

bull Duchesne JC Heaney J Guidry C McSwain N Jr Meade P Cohen M Schreiber M Inaba K Skiada D Demetriades D Holcomb J Wade C Cotton B Diluting the benefits of hemostatic resuscitation A multi-institutional analysis J Trauma Acute Care Surg 2013 Jul75(1)76-82 doi 101097TA0b013e3182987df3

bull Guidry C Gleeson E Simms ER Stuke L Meade P McSwain NE Jr Duchesne JC Initial assessment on the impact of crystalloids versus colloids during damage control resuscitation J Surg Res 2013 Jun 15 pii S0022-4804(13)00568-4 doi 101016jjss201305086 [Epub ahead of print]

bull Perel P Roberts I Ker K Colloids versus crystalloids for fluid resuscitation in critically ill patients Cochrane Database Syst Rev 2013 Feb 282CD000567 doi 10100214651858CD000567pub6

bull Zarychanski R Abou-Setta AM Turgeon AF et al Association of Hydroxyethyl Starch Administration With Mortality and Acute Kidney Injury in Critically Ill Patients Requiring Volume Resuscitation A Systematic Review and Meta-analysis JAMA 2013309(7)678-688 doi101001jama2013430

bull Bulger EM May S Kerby JD Emerson S Stiell IG Schreiber MA Brasel KJ Tisherman SA Coimbra R Rizoli S Minei JP Hata JS Sopko G Evans DC Hoyt DB ROC investigators Out-of-hospital hypertonic resuscitation after traumatic hypovolemic shock a randomized placebo controlled trial Ann Surg 2011 Mar253(3)431-41 doi 101097SLA0b013e3181fcdb22

bull Vassar MJ Fischer RP OBrien PE Bachulis BL Chambers JA Hoyt DB Holcroft JW A multicenter trial for resuscitation of injured patients with 75 sodium chloride The effect of added dextran 70 The Multicenter Group for the Study of Hypertonic Saline in Trauma Patients Arch Surg 1993 Sep128(9)1003-11 discussion 1011-3

bull Cooper DJ Myles PS McDermott FT Murray LJ Laidlaw J Cooper G Tremayne AB Bernard SS Ponsford J HTS Study Investigators Prehospital hypertonic saline resuscitation of patients with hypotension and severe traumatic brain injury a randomized controlled trial JAMA 2004 Mar 17291(11)1350-7

bull Duke MD Guidry C Guice J Stuke L Marr AB Hunt JP Meade P McSwain NE Jr Duchesne JC Restrictive fluid resuscitation in combination with damage control resuscitation time for adaptation J Trauma Acute Care Surg 2012 Sep73(3)674-8 doi 101097TA0b013e318265ce1f

bull Pidcoke HF Aden JK Mora AG Borgman MA Spinella PC Dubick MA Blackbourne LH Cap AP Ten-year analysis of transfusion in Operation Iraqi Freedom and Operation Enduring Freedom increased plasma and platelet use correlates with improved survival J Trauma Acute Care Surg 2012 Dec73(6 Suppl 5)S445-52 doi 101097TA0b013e3182754796

bull Morrison CA Carrick MM Norman MA Scott BG Welsh FJ Tsai P Liscum KR Wall MJ Jr Mattox KL Hypotensive resuscitation strategy reduces transfusion requirements and severe postoperative coagulopathy in trauma patients with hemorrhagic shock preliminary results of a randomized controlled trial J Trauma 2011 Mar70(3)652-63 doi 101097TA0b013e31820e77ea

bull Ley EJ Clond MA Srour MK Barnajian M Mirocha J Margulies DR Salim A Emergency department crystalloid resuscitation of 15 L or more is associated with increased mortality in elderly and nonelderly trauma patients J Trauma 2011 Feb70(2)398-400 doi 101097TA0b013e318208f99b

bull Kasotakis G Sideris A Yang Y de Moya M Alam H King DR Tompkins R Velmahos G Inflammation and Host Response to Injury Investigators Aggressive early crystalloid resuscitation adversely affects outcomes in adult blunt trauma patients an analysis of the Glue Grant database J Trauma Acute Care Surg 2013 May74(5)1215-21 discussion 1221-2 doi 101097TA0b013e3182826e13

bull Neal MD Hoffman MK Cuschieri J Minei JP Maier RV Harbrecht BG Billiar TR Peitzman AB Moore EE Cohen MJ Sperry JL Crystalloid to packed red blood cell transfusion ratio in the massively transfused patient when a little goes a long way J Trauma Acute Care Surg 2012 Apr72(4)892-8 doi 101097TA0b013e31823d84a7

bull Niles SE McLaughlin DF Perkins JG et al Increased mortality associated with the early coagulopathy of trauma in combat casualties J Trauma 2008641459-63

bull Brohi K Singh J Heron M Coats T Acute traumatic coagulopathy J Trauma 2003541127-30

bull Cotton BA Gunter OL Isbell J et al Damage control hematology the impact of a trauma exsanguination protocol on survival and blood product utilization J Trauma 2008641177-82

bull Keneally RJ1 Parsons AM1 Willett PB1 Warm fresh whole blood and thoracic traumain iraq and afghanistan J Emerg Trauma Shock 2015 Jan-Mar8(1)21-5

bull Spinella PC1 Perkins JG Grathwohl KW Beekley AC Holcomb JB Warm fresh whole blood is independently associated with improved survival for patients with combat-related traumatic injuries J Trauma 2009 Apr66(4 Suppl)S69-76

bull Wafaisade A1 Lefering R2 Bouillon B3 Boumlhmer AB4 Gaumlszligler M5 Ruppert M5 TraumaRegister DGU Prehospital administration of tranexamic acid in trauma patients Crit Care 2016 May 1220(1)143

bull Ausset S1 Glassberg E Nadler R Sunde G Cap AP Hoffmann C Plang S Sailliol A Tranexamic acid as part of remote damage-control resuscitation in the prehospital setting A critical appraisal of the medical literature and available alternatives J Trauma Acute Care Surg 2015 Jun78(6 Suppl 1)S70-5

bull CRASH-2 trial collaborators Shakur H Roberts I Bautista R Caballero J Coats T Dewan Y El-Sayed H Gogichaishvili T Gupta S Herrera J Hunt B Iribhogbe P Izurieta M Khamis H Komolafe E Marrero MA Mejiacutea-Mantilla J Miranda J Morales C Olaomi O Olldashi F Perel P Peto R Ramana PV Ravi RR Yutthakasemsunt S Effects of tranexamic acid on death vascular occlusive events and blood transfusion in trauma patients with significant haemorrhage (CRASH-2) a randomised placebo-controlled trial Lancet 2010 Jul 3376(9734)23-32

bull Morrison JJ1 Dubose JJ Rasmussen TE Midwinter MJ Military Application of Tranexamic Acid in Trauma Emergency Resuscitation (MATTERs) Study Arch Surg 2012 Feb147(2)113-9

bull Morrison JJ1 Ross JD Dubose JJ Jansen JO Midwinter MJ Rasmussen TE Association of cryoprecipitate and tranexamic acid with improved survival following wartime injury findings from the MATTERs II Study JAMA Surg 2013 Mar148(3)218-25

What kills trauma

patients

bull Hypothermia

bull 1deg makes a difference

bull Coagulopathy

bull 25-38 arrive coagulopathic

bull 75 who require MTP

bull Acidosis

bull Respiratory failure only kills 6

DEATH

ACIDOSIS

COAGULOPATHY

HYPO-THERMIA

Damage Control

bull Fire suppression

bull Control flooding

bull Maintain mission

capability

bull Achieve hemostasis

bull Maintain perfusion

bull Restore physiology

Traditional trauma

resuscitation

bull ldquoStart 2 large bore IVs and give up to 2L of crystalloidrdquo

bull -ATLS Manual 9th ed

bull Traditional isotonic crystalloids NS LR

bull Keep SBP gt90

bull Whatrsquos normal about Normal Saline

Solution Na Cl K Ca Mg Lact Acet Gluc

Dex

pH Osm

Plasma 144 107 5 5 15 74 290

09NaCl

ldquonormal salinerdquo

154 154 54 308

Lactated Ringers 130 109 4 3 28 65 273

Normosol 140 98 5 3 27 23 74 295

Plasmalyte A 140 98 5 3 27 23 74 294

Plasmalyte 148 140 98 5 3 27 23 55 294

Hextend 143 124 3 5 09 28 59 307

Hespan 154 154 59 309

Crystalloids in

resuscitation

bull Higher mortality with higher crystalloid volumes in

patients receiving massive transfusion Higher rates of

renal failure too

bull More fluid

bull Volumes gt 15 L of crystalloid = higher mortality

bull Increased ALI ARDS MOSF ICU and hospital LOS

bull Crystalloidblood ratio gt 15L1u associated with higher

mortality and morbidity

Permissive Hypotension

bull Cannon W Fraser J Cowell E The Preventative Treatment of Wound Shock JAMA 1918618-621

bull Poor outcomes with IV fluid resuscitation

bull Forgotten until the 1980s

bull Bickell WH Wall MH Pepe PE Martin RR Ginger VF Allen MK Mattox KL Immediate versus delayed fluid resuscitation for Hypotensive patients with penetrating torso injuries N Engl J Med 1994 Oct 27 3311105-9

bull Maintain SBP 90 mmHg

bull Not good for CNS injuries- linear relationship

Colloids in resuscitation

bull Expensive (20x)

bull No benefit

bull Possible harm death AKI

bull HOWEVER trauma patient cohorts small

bull ldquoThe paper reviewed the use of a variety of hetastarches in a variety of volumes for a variety of indications This study was clearly not designed to answer the question about the risksbenefits of Hextend used in a hypotensive resuscitation strategy for combat casualties when blood products are not available ndash and clearly does not provide that answerrdquo - CoTCCC

Blood Ratios

bull The old LOTS of pRBCs = oxygen carrying capacity

bull The now 111 ratio

bull Replace coagulation factorsplatelets

Blood

bull O- for females at or below CBA

bull O+ for everyone else

bull FFP AB is universal donor

bull A is the next safest

Who Needs Massive

Transfusion

bull Systolic BP lt110

bull HRgt 105

bull Hct lt 32

bull pH lt 725

bull 3 of the 4 70 likelihood

bull 44 85 likelihood

bull INR gt 14 (5x mortality)

bull StO2 lt 75

Who Needs Massive

Transfusion

bull Uncontrolled truncal axillary neck or groin bleeding

bull Uncontrolled bleeding secondary to massive soft tissue

injuries

bull Proximal amputation or mangled extremity

bull Clinical signs of coagulopathy

bull Severe hypothermia with blood loss

Which should we give

first

bull We have decent oxygen carrying capacity when anemic

bull Plasma first transfusion may be better

bull Fix the coagulopathy hypothermia acidosis

bull Prehospital freeze dried plasma (FDP)

bull Being studied by US military

bull Used by our European colleagues

bull not FDA approved in the US currently

Fibrinogen

bull Fresh whole blood 1000 mg of fibrinogen

bull FFP 400 mg

bull Platelets 80 mg

bull Cryoprecipitate 2500 mg

bull Transfusion with high ratios of fibrinogen to RBCs have

shown survival benefit

Fresh Whole Blood

Blood

bull Fresh whole blood AT LEAST equivalent to components

bull May improve survival

bull Restricted fluid resuscitation (lt1500 mL crystalloid) OR

of death 069

bull DCR Less fluid (5 vs 14 L) less pRBCs (7 u vs 13 u)

less ldquolethal triadrdquo (46 vs 80) survival OR 25

TCCC Order of preference

for fluid resuscitation

bull Fresh whole blood

bull PRBCsFFPPlatelets in 111 ratio

bull PRBCsFFP in 11 ratio

bull PRBCs or FFP

bull Plasmalyte Normosol

bull Lactated Ringers

bull Not recommended Normal Saline

Tranexamic Acid

bull Antithrombolytic

bull ldquoHyperfibrinolysis of traumardquo

bull 1g over 10 min

bull Giving it faster can cause hypotension

bull May give up to 5g (studied up to 250mgkg)

bull Re-dose if hemorrhage is ongoing

Tranexamic Acid

bull CRASH-2 bull Given across a wide spectrum of trauma patients in 40 countries

bull ARR 15

bull Poorly controlled only half went to OR

bull MATTERs bull 17 vs 239 mortality

bull Benefit greatest in those getting MTP

bull MATTERs II bull TXA vs Cryo vs TXA+Cryo

bull 116 vs 236 mortality

bull Best benefit lt1h after injury

bull Some benefit lt3h after injury

bull Possible harm gt3h after injury

Tranexamic Acid

bull CRASH-2 TBI

bull Basically a wash

bull Cole Davenport Brohi TXA did not affect mortality in

overall or non-shock cohorts

bull MVA showed OR of MOF 027 and death 016

bull Valle Allen Higher mortality with TXA if needing gt2L

PRBCs

bull Given 97 min after ADMISSION and after transfusion

Factor VIIa

bull No studies showing mortality benefit

bull Studies showing decreased blood loss

bull $45000dose

bull May consider if still bleeding after TXA

Metabolic acidosis

bull Keep pH above 72

bull Administer THAM (Tromethamine solution) or sodium

bicarbonate to maintain pH

bull Weight in kg x base deficit x 11 = volume of THAM

solution to give (18g500mL)

bull Weight in kg x base deficit x 02 = volume of sodium

bicarb solution to give

Calcium

bull Calcium used up in clots

bull Calcium gobbled up by citrate in stored blood

bull Maintain ionized iCa gt 10 (run on ABG machine)

bull 1g Ca Gluconate for every 4 u FFP

Storage lesions

bull Stored blood is acidic

bull Calcium is chelated by preservatives

bull Platelets decline in function

Thromboelastography

(TEG)

bull Gives a better picture of coagulation status

bull Measures time to initiate clot

bull Speed of formation

bull Strength of clot

bull Fibrinolysis

bull Can help guide transfusion therapy

bull Better outcomes at gt10u PRBCs

bull Fewer units of blood

TEG

TEG Value Transfuse

TEG-ACT gt 140 FFP

R time gt 10 FFP

K time gt 3 Cryo

A angle Cry +- Platelets

MA lt 50 Platelets

LY30 gt3 TXA

REBOA

bull Resuscitative Endovascular Balloon Occlusion of the

Aorta

ER REBOA

Bottom Line

bull Keep them WARM

bull Little to no crystalloid

bull Hypotension is bad for brain injuries

bull Think about MT early

bull 111 ratio

bull Give TXA early

bull Calcium

bull Fix acidosis

bull Balogh Z McKinley BA Cocanour CS Kozar RA Valdivia A Sailors RM Moore FA Supra-normal trauma resuscitation causes more cases of abdominal compartment syndrome Arch Surg 138637-643 2003

bull Duchesne JC Heaney J Guidry C McSwain N Jr Meade P Cohen M Schreiber M Inaba K Skiada D Demetriades D Holcomb J Wade C Cotton B Diluting the benefits of hemostatic resuscitation A multi-institutional analysis J Trauma Acute Care Surg 2013 Jul75(1)76-82 doi 101097TA0b013e3182987df3

bull Guidry C Gleeson E Simms ER Stuke L Meade P McSwain NE Jr Duchesne JC Initial assessment on the impact of crystalloids versus colloids during damage control resuscitation J Surg Res 2013 Jun 15 pii S0022-4804(13)00568-4 doi 101016jjss201305086 [Epub ahead of print]

bull Perel P Roberts I Ker K Colloids versus crystalloids for fluid resuscitation in critically ill patients Cochrane Database Syst Rev 2013 Feb 282CD000567 doi 10100214651858CD000567pub6

bull Zarychanski R Abou-Setta AM Turgeon AF et al Association of Hydroxyethyl Starch Administration With Mortality and Acute Kidney Injury in Critically Ill Patients Requiring Volume Resuscitation A Systematic Review and Meta-analysis JAMA 2013309(7)678-688 doi101001jama2013430

bull Bulger EM May S Kerby JD Emerson S Stiell IG Schreiber MA Brasel KJ Tisherman SA Coimbra R Rizoli S Minei JP Hata JS Sopko G Evans DC Hoyt DB ROC investigators Out-of-hospital hypertonic resuscitation after traumatic hypovolemic shock a randomized placebo controlled trial Ann Surg 2011 Mar253(3)431-41 doi 101097SLA0b013e3181fcdb22

bull Vassar MJ Fischer RP OBrien PE Bachulis BL Chambers JA Hoyt DB Holcroft JW A multicenter trial for resuscitation of injured patients with 75 sodium chloride The effect of added dextran 70 The Multicenter Group for the Study of Hypertonic Saline in Trauma Patients Arch Surg 1993 Sep128(9)1003-11 discussion 1011-3

bull Cooper DJ Myles PS McDermott FT Murray LJ Laidlaw J Cooper G Tremayne AB Bernard SS Ponsford J HTS Study Investigators Prehospital hypertonic saline resuscitation of patients with hypotension and severe traumatic brain injury a randomized controlled trial JAMA 2004 Mar 17291(11)1350-7

bull Duke MD Guidry C Guice J Stuke L Marr AB Hunt JP Meade P McSwain NE Jr Duchesne JC Restrictive fluid resuscitation in combination with damage control resuscitation time for adaptation J Trauma Acute Care Surg 2012 Sep73(3)674-8 doi 101097TA0b013e318265ce1f

bull Pidcoke HF Aden JK Mora AG Borgman MA Spinella PC Dubick MA Blackbourne LH Cap AP Ten-year analysis of transfusion in Operation Iraqi Freedom and Operation Enduring Freedom increased plasma and platelet use correlates with improved survival J Trauma Acute Care Surg 2012 Dec73(6 Suppl 5)S445-52 doi 101097TA0b013e3182754796

bull Morrison CA Carrick MM Norman MA Scott BG Welsh FJ Tsai P Liscum KR Wall MJ Jr Mattox KL Hypotensive resuscitation strategy reduces transfusion requirements and severe postoperative coagulopathy in trauma patients with hemorrhagic shock preliminary results of a randomized controlled trial J Trauma 2011 Mar70(3)652-63 doi 101097TA0b013e31820e77ea

bull Ley EJ Clond MA Srour MK Barnajian M Mirocha J Margulies DR Salim A Emergency department crystalloid resuscitation of 15 L or more is associated with increased mortality in elderly and nonelderly trauma patients J Trauma 2011 Feb70(2)398-400 doi 101097TA0b013e318208f99b

bull Kasotakis G Sideris A Yang Y de Moya M Alam H King DR Tompkins R Velmahos G Inflammation and Host Response to Injury Investigators Aggressive early crystalloid resuscitation adversely affects outcomes in adult blunt trauma patients an analysis of the Glue Grant database J Trauma Acute Care Surg 2013 May74(5)1215-21 discussion 1221-2 doi 101097TA0b013e3182826e13

bull Neal MD Hoffman MK Cuschieri J Minei JP Maier RV Harbrecht BG Billiar TR Peitzman AB Moore EE Cohen MJ Sperry JL Crystalloid to packed red blood cell transfusion ratio in the massively transfused patient when a little goes a long way J Trauma Acute Care Surg 2012 Apr72(4)892-8 doi 101097TA0b013e31823d84a7

bull Niles SE McLaughlin DF Perkins JG et al Increased mortality associated with the early coagulopathy of trauma in combat casualties J Trauma 2008641459-63

bull Brohi K Singh J Heron M Coats T Acute traumatic coagulopathy J Trauma 2003541127-30

bull Cotton BA Gunter OL Isbell J et al Damage control hematology the impact of a trauma exsanguination protocol on survival and blood product utilization J Trauma 2008641177-82

bull Keneally RJ1 Parsons AM1 Willett PB1 Warm fresh whole blood and thoracic traumain iraq and afghanistan J Emerg Trauma Shock 2015 Jan-Mar8(1)21-5

bull Spinella PC1 Perkins JG Grathwohl KW Beekley AC Holcomb JB Warm fresh whole blood is independently associated with improved survival for patients with combat-related traumatic injuries J Trauma 2009 Apr66(4 Suppl)S69-76

bull Wafaisade A1 Lefering R2 Bouillon B3 Boumlhmer AB4 Gaumlszligler M5 Ruppert M5 TraumaRegister DGU Prehospital administration of tranexamic acid in trauma patients Crit Care 2016 May 1220(1)143

bull Ausset S1 Glassberg E Nadler R Sunde G Cap AP Hoffmann C Plang S Sailliol A Tranexamic acid as part of remote damage-control resuscitation in the prehospital setting A critical appraisal of the medical literature and available alternatives J Trauma Acute Care Surg 2015 Jun78(6 Suppl 1)S70-5

bull CRASH-2 trial collaborators Shakur H Roberts I Bautista R Caballero J Coats T Dewan Y El-Sayed H Gogichaishvili T Gupta S Herrera J Hunt B Iribhogbe P Izurieta M Khamis H Komolafe E Marrero MA Mejiacutea-Mantilla J Miranda J Morales C Olaomi O Olldashi F Perel P Peto R Ramana PV Ravi RR Yutthakasemsunt S Effects of tranexamic acid on death vascular occlusive events and blood transfusion in trauma patients with significant haemorrhage (CRASH-2) a randomised placebo-controlled trial Lancet 2010 Jul 3376(9734)23-32

bull Morrison JJ1 Dubose JJ Rasmussen TE Midwinter MJ Military Application of Tranexamic Acid in Trauma Emergency Resuscitation (MATTERs) Study Arch Surg 2012 Feb147(2)113-9

bull Morrison JJ1 Ross JD Dubose JJ Jansen JO Midwinter MJ Rasmussen TE Association of cryoprecipitate and tranexamic acid with improved survival following wartime injury findings from the MATTERs II Study JAMA Surg 2013 Mar148(3)218-25

Damage Control

bull Fire suppression

bull Control flooding

bull Maintain mission

capability

bull Achieve hemostasis

bull Maintain perfusion

bull Restore physiology

Traditional trauma

resuscitation

bull ldquoStart 2 large bore IVs and give up to 2L of crystalloidrdquo

bull -ATLS Manual 9th ed

bull Traditional isotonic crystalloids NS LR

bull Keep SBP gt90

bull Whatrsquos normal about Normal Saline

Solution Na Cl K Ca Mg Lact Acet Gluc

Dex

pH Osm

Plasma 144 107 5 5 15 74 290

09NaCl

ldquonormal salinerdquo

154 154 54 308

Lactated Ringers 130 109 4 3 28 65 273

Normosol 140 98 5 3 27 23 74 295

Plasmalyte A 140 98 5 3 27 23 74 294

Plasmalyte 148 140 98 5 3 27 23 55 294

Hextend 143 124 3 5 09 28 59 307

Hespan 154 154 59 309

Crystalloids in

resuscitation

bull Higher mortality with higher crystalloid volumes in

patients receiving massive transfusion Higher rates of

renal failure too

bull More fluid

bull Volumes gt 15 L of crystalloid = higher mortality

bull Increased ALI ARDS MOSF ICU and hospital LOS

bull Crystalloidblood ratio gt 15L1u associated with higher

mortality and morbidity

Permissive Hypotension

bull Cannon W Fraser J Cowell E The Preventative Treatment of Wound Shock JAMA 1918618-621

bull Poor outcomes with IV fluid resuscitation

bull Forgotten until the 1980s

bull Bickell WH Wall MH Pepe PE Martin RR Ginger VF Allen MK Mattox KL Immediate versus delayed fluid resuscitation for Hypotensive patients with penetrating torso injuries N Engl J Med 1994 Oct 27 3311105-9

bull Maintain SBP 90 mmHg

bull Not good for CNS injuries- linear relationship

Colloids in resuscitation

bull Expensive (20x)

bull No benefit

bull Possible harm death AKI

bull HOWEVER trauma patient cohorts small

bull ldquoThe paper reviewed the use of a variety of hetastarches in a variety of volumes for a variety of indications This study was clearly not designed to answer the question about the risksbenefits of Hextend used in a hypotensive resuscitation strategy for combat casualties when blood products are not available ndash and clearly does not provide that answerrdquo - CoTCCC

Blood Ratios

bull The old LOTS of pRBCs = oxygen carrying capacity

bull The now 111 ratio

bull Replace coagulation factorsplatelets

Blood

bull O- for females at or below CBA

bull O+ for everyone else

bull FFP AB is universal donor

bull A is the next safest

Who Needs Massive

Transfusion

bull Systolic BP lt110

bull HRgt 105

bull Hct lt 32

bull pH lt 725

bull 3 of the 4 70 likelihood

bull 44 85 likelihood

bull INR gt 14 (5x mortality)

bull StO2 lt 75

Who Needs Massive

Transfusion

bull Uncontrolled truncal axillary neck or groin bleeding

bull Uncontrolled bleeding secondary to massive soft tissue

injuries

bull Proximal amputation or mangled extremity

bull Clinical signs of coagulopathy

bull Severe hypothermia with blood loss

Which should we give

first

bull We have decent oxygen carrying capacity when anemic

bull Plasma first transfusion may be better

bull Fix the coagulopathy hypothermia acidosis

bull Prehospital freeze dried plasma (FDP)

bull Being studied by US military

bull Used by our European colleagues

bull not FDA approved in the US currently

Fibrinogen

bull Fresh whole blood 1000 mg of fibrinogen

bull FFP 400 mg

bull Platelets 80 mg

bull Cryoprecipitate 2500 mg

bull Transfusion with high ratios of fibrinogen to RBCs have

shown survival benefit

Fresh Whole Blood

Blood

bull Fresh whole blood AT LEAST equivalent to components

bull May improve survival

bull Restricted fluid resuscitation (lt1500 mL crystalloid) OR

of death 069

bull DCR Less fluid (5 vs 14 L) less pRBCs (7 u vs 13 u)

less ldquolethal triadrdquo (46 vs 80) survival OR 25

TCCC Order of preference

for fluid resuscitation

bull Fresh whole blood

bull PRBCsFFPPlatelets in 111 ratio

bull PRBCsFFP in 11 ratio

bull PRBCs or FFP

bull Plasmalyte Normosol

bull Lactated Ringers

bull Not recommended Normal Saline

Tranexamic Acid

bull Antithrombolytic

bull ldquoHyperfibrinolysis of traumardquo

bull 1g over 10 min

bull Giving it faster can cause hypotension

bull May give up to 5g (studied up to 250mgkg)

bull Re-dose if hemorrhage is ongoing

Tranexamic Acid

bull CRASH-2 bull Given across a wide spectrum of trauma patients in 40 countries

bull ARR 15

bull Poorly controlled only half went to OR

bull MATTERs bull 17 vs 239 mortality

bull Benefit greatest in those getting MTP

bull MATTERs II bull TXA vs Cryo vs TXA+Cryo

bull 116 vs 236 mortality

bull Best benefit lt1h after injury

bull Some benefit lt3h after injury

bull Possible harm gt3h after injury

Tranexamic Acid

bull CRASH-2 TBI

bull Basically a wash

bull Cole Davenport Brohi TXA did not affect mortality in

overall or non-shock cohorts

bull MVA showed OR of MOF 027 and death 016

bull Valle Allen Higher mortality with TXA if needing gt2L

PRBCs

bull Given 97 min after ADMISSION and after transfusion

Factor VIIa

bull No studies showing mortality benefit

bull Studies showing decreased blood loss

bull $45000dose

bull May consider if still bleeding after TXA

Metabolic acidosis

bull Keep pH above 72

bull Administer THAM (Tromethamine solution) or sodium

bicarbonate to maintain pH

bull Weight in kg x base deficit x 11 = volume of THAM

solution to give (18g500mL)

bull Weight in kg x base deficit x 02 = volume of sodium

bicarb solution to give

Calcium

bull Calcium used up in clots

bull Calcium gobbled up by citrate in stored blood

bull Maintain ionized iCa gt 10 (run on ABG machine)

bull 1g Ca Gluconate for every 4 u FFP

Storage lesions

bull Stored blood is acidic

bull Calcium is chelated by preservatives

bull Platelets decline in function

Thromboelastography

(TEG)

bull Gives a better picture of coagulation status

bull Measures time to initiate clot

bull Speed of formation

bull Strength of clot

bull Fibrinolysis

bull Can help guide transfusion therapy

bull Better outcomes at gt10u PRBCs

bull Fewer units of blood

TEG

TEG Value Transfuse

TEG-ACT gt 140 FFP

R time gt 10 FFP

K time gt 3 Cryo

A angle Cry +- Platelets

MA lt 50 Platelets

LY30 gt3 TXA

REBOA

bull Resuscitative Endovascular Balloon Occlusion of the

Aorta

ER REBOA

Bottom Line

bull Keep them WARM

bull Little to no crystalloid

bull Hypotension is bad for brain injuries

bull Think about MT early

bull 111 ratio

bull Give TXA early

bull Calcium

bull Fix acidosis

bull Balogh Z McKinley BA Cocanour CS Kozar RA Valdivia A Sailors RM Moore FA Supra-normal trauma resuscitation causes more cases of abdominal compartment syndrome Arch Surg 138637-643 2003

bull Duchesne JC Heaney J Guidry C McSwain N Jr Meade P Cohen M Schreiber M Inaba K Skiada D Demetriades D Holcomb J Wade C Cotton B Diluting the benefits of hemostatic resuscitation A multi-institutional analysis J Trauma Acute Care Surg 2013 Jul75(1)76-82 doi 101097TA0b013e3182987df3

bull Guidry C Gleeson E Simms ER Stuke L Meade P McSwain NE Jr Duchesne JC Initial assessment on the impact of crystalloids versus colloids during damage control resuscitation J Surg Res 2013 Jun 15 pii S0022-4804(13)00568-4 doi 101016jjss201305086 [Epub ahead of print]

bull Perel P Roberts I Ker K Colloids versus crystalloids for fluid resuscitation in critically ill patients Cochrane Database Syst Rev 2013 Feb 282CD000567 doi 10100214651858CD000567pub6

bull Zarychanski R Abou-Setta AM Turgeon AF et al Association of Hydroxyethyl Starch Administration With Mortality and Acute Kidney Injury in Critically Ill Patients Requiring Volume Resuscitation A Systematic Review and Meta-analysis JAMA 2013309(7)678-688 doi101001jama2013430

bull Bulger EM May S Kerby JD Emerson S Stiell IG Schreiber MA Brasel KJ Tisherman SA Coimbra R Rizoli S Minei JP Hata JS Sopko G Evans DC Hoyt DB ROC investigators Out-of-hospital hypertonic resuscitation after traumatic hypovolemic shock a randomized placebo controlled trial Ann Surg 2011 Mar253(3)431-41 doi 101097SLA0b013e3181fcdb22

bull Vassar MJ Fischer RP OBrien PE Bachulis BL Chambers JA Hoyt DB Holcroft JW A multicenter trial for resuscitation of injured patients with 75 sodium chloride The effect of added dextran 70 The Multicenter Group for the Study of Hypertonic Saline in Trauma Patients Arch Surg 1993 Sep128(9)1003-11 discussion 1011-3

bull Cooper DJ Myles PS McDermott FT Murray LJ Laidlaw J Cooper G Tremayne AB Bernard SS Ponsford J HTS Study Investigators Prehospital hypertonic saline resuscitation of patients with hypotension and severe traumatic brain injury a randomized controlled trial JAMA 2004 Mar 17291(11)1350-7

bull Duke MD Guidry C Guice J Stuke L Marr AB Hunt JP Meade P McSwain NE Jr Duchesne JC Restrictive fluid resuscitation in combination with damage control resuscitation time for adaptation J Trauma Acute Care Surg 2012 Sep73(3)674-8 doi 101097TA0b013e318265ce1f

bull Pidcoke HF Aden JK Mora AG Borgman MA Spinella PC Dubick MA Blackbourne LH Cap AP Ten-year analysis of transfusion in Operation Iraqi Freedom and Operation Enduring Freedom increased plasma and platelet use correlates with improved survival J Trauma Acute Care Surg 2012 Dec73(6 Suppl 5)S445-52 doi 101097TA0b013e3182754796

bull Morrison CA Carrick MM Norman MA Scott BG Welsh FJ Tsai P Liscum KR Wall MJ Jr Mattox KL Hypotensive resuscitation strategy reduces transfusion requirements and severe postoperative coagulopathy in trauma patients with hemorrhagic shock preliminary results of a randomized controlled trial J Trauma 2011 Mar70(3)652-63 doi 101097TA0b013e31820e77ea

bull Ley EJ Clond MA Srour MK Barnajian M Mirocha J Margulies DR Salim A Emergency department crystalloid resuscitation of 15 L or more is associated with increased mortality in elderly and nonelderly trauma patients J Trauma 2011 Feb70(2)398-400 doi 101097TA0b013e318208f99b

bull Kasotakis G Sideris A Yang Y de Moya M Alam H King DR Tompkins R Velmahos G Inflammation and Host Response to Injury Investigators Aggressive early crystalloid resuscitation adversely affects outcomes in adult blunt trauma patients an analysis of the Glue Grant database J Trauma Acute Care Surg 2013 May74(5)1215-21 discussion 1221-2 doi 101097TA0b013e3182826e13

bull Neal MD Hoffman MK Cuschieri J Minei JP Maier RV Harbrecht BG Billiar TR Peitzman AB Moore EE Cohen MJ Sperry JL Crystalloid to packed red blood cell transfusion ratio in the massively transfused patient when a little goes a long way J Trauma Acute Care Surg 2012 Apr72(4)892-8 doi 101097TA0b013e31823d84a7

bull Niles SE McLaughlin DF Perkins JG et al Increased mortality associated with the early coagulopathy of trauma in combat casualties J Trauma 2008641459-63

bull Brohi K Singh J Heron M Coats T Acute traumatic coagulopathy J Trauma 2003541127-30

bull Cotton BA Gunter OL Isbell J et al Damage control hematology the impact of a trauma exsanguination protocol on survival and blood product utilization J Trauma 2008641177-82

bull Keneally RJ1 Parsons AM1 Willett PB1 Warm fresh whole blood and thoracic traumain iraq and afghanistan J Emerg Trauma Shock 2015 Jan-Mar8(1)21-5

bull Spinella PC1 Perkins JG Grathwohl KW Beekley AC Holcomb JB Warm fresh whole blood is independently associated with improved survival for patients with combat-related traumatic injuries J Trauma 2009 Apr66(4 Suppl)S69-76

bull Wafaisade A1 Lefering R2 Bouillon B3 Boumlhmer AB4 Gaumlszligler M5 Ruppert M5 TraumaRegister DGU Prehospital administration of tranexamic acid in trauma patients Crit Care 2016 May 1220(1)143

bull Ausset S1 Glassberg E Nadler R Sunde G Cap AP Hoffmann C Plang S Sailliol A Tranexamic acid as part of remote damage-control resuscitation in the prehospital setting A critical appraisal of the medical literature and available alternatives J Trauma Acute Care Surg 2015 Jun78(6 Suppl 1)S70-5

bull CRASH-2 trial collaborators Shakur H Roberts I Bautista R Caballero J Coats T Dewan Y El-Sayed H Gogichaishvili T Gupta S Herrera J Hunt B Iribhogbe P Izurieta M Khamis H Komolafe E Marrero MA Mejiacutea-Mantilla J Miranda J Morales C Olaomi O Olldashi F Perel P Peto R Ramana PV Ravi RR Yutthakasemsunt S Effects of tranexamic acid on death vascular occlusive events and blood transfusion in trauma patients with significant haemorrhage (CRASH-2) a randomised placebo-controlled trial Lancet 2010 Jul 3376(9734)23-32

bull Morrison JJ1 Dubose JJ Rasmussen TE Midwinter MJ Military Application of Tranexamic Acid in Trauma Emergency Resuscitation (MATTERs) Study Arch Surg 2012 Feb147(2)113-9

bull Morrison JJ1 Ross JD Dubose JJ Jansen JO Midwinter MJ Rasmussen TE Association of cryoprecipitate and tranexamic acid with improved survival following wartime injury findings from the MATTERs II Study JAMA Surg 2013 Mar148(3)218-25

Traditional trauma

resuscitation

bull ldquoStart 2 large bore IVs and give up to 2L of crystalloidrdquo

bull -ATLS Manual 9th ed

bull Traditional isotonic crystalloids NS LR

bull Keep SBP gt90

bull Whatrsquos normal about Normal Saline

Solution Na Cl K Ca Mg Lact Acet Gluc

Dex

pH Osm

Plasma 144 107 5 5 15 74 290

09NaCl

ldquonormal salinerdquo

154 154 54 308

Lactated Ringers 130 109 4 3 28 65 273

Normosol 140 98 5 3 27 23 74 295

Plasmalyte A 140 98 5 3 27 23 74 294

Plasmalyte 148 140 98 5 3 27 23 55 294

Hextend 143 124 3 5 09 28 59 307

Hespan 154 154 59 309

Crystalloids in

resuscitation

bull Higher mortality with higher crystalloid volumes in

patients receiving massive transfusion Higher rates of

renal failure too

bull More fluid

bull Volumes gt 15 L of crystalloid = higher mortality

bull Increased ALI ARDS MOSF ICU and hospital LOS

bull Crystalloidblood ratio gt 15L1u associated with higher

mortality and morbidity

Permissive Hypotension

bull Cannon W Fraser J Cowell E The Preventative Treatment of Wound Shock JAMA 1918618-621

bull Poor outcomes with IV fluid resuscitation

bull Forgotten until the 1980s

bull Bickell WH Wall MH Pepe PE Martin RR Ginger VF Allen MK Mattox KL Immediate versus delayed fluid resuscitation for Hypotensive patients with penetrating torso injuries N Engl J Med 1994 Oct 27 3311105-9

bull Maintain SBP 90 mmHg

bull Not good for CNS injuries- linear relationship

Colloids in resuscitation

bull Expensive (20x)

bull No benefit

bull Possible harm death AKI

bull HOWEVER trauma patient cohorts small

bull ldquoThe paper reviewed the use of a variety of hetastarches in a variety of volumes for a variety of indications This study was clearly not designed to answer the question about the risksbenefits of Hextend used in a hypotensive resuscitation strategy for combat casualties when blood products are not available ndash and clearly does not provide that answerrdquo - CoTCCC

Blood Ratios

bull The old LOTS of pRBCs = oxygen carrying capacity

bull The now 111 ratio

bull Replace coagulation factorsplatelets

Blood

bull O- for females at or below CBA

bull O+ for everyone else

bull FFP AB is universal donor

bull A is the next safest

Who Needs Massive

Transfusion

bull Systolic BP lt110

bull HRgt 105

bull Hct lt 32

bull pH lt 725

bull 3 of the 4 70 likelihood

bull 44 85 likelihood

bull INR gt 14 (5x mortality)

bull StO2 lt 75

Who Needs Massive

Transfusion

bull Uncontrolled truncal axillary neck or groin bleeding

bull Uncontrolled bleeding secondary to massive soft tissue

injuries

bull Proximal amputation or mangled extremity

bull Clinical signs of coagulopathy

bull Severe hypothermia with blood loss

Which should we give

first

bull We have decent oxygen carrying capacity when anemic

bull Plasma first transfusion may be better

bull Fix the coagulopathy hypothermia acidosis

bull Prehospital freeze dried plasma (FDP)

bull Being studied by US military

bull Used by our European colleagues

bull not FDA approved in the US currently

Fibrinogen

bull Fresh whole blood 1000 mg of fibrinogen

bull FFP 400 mg

bull Platelets 80 mg

bull Cryoprecipitate 2500 mg

bull Transfusion with high ratios of fibrinogen to RBCs have

shown survival benefit

Fresh Whole Blood

Blood

bull Fresh whole blood AT LEAST equivalent to components

bull May improve survival

bull Restricted fluid resuscitation (lt1500 mL crystalloid) OR

of death 069

bull DCR Less fluid (5 vs 14 L) less pRBCs (7 u vs 13 u)

less ldquolethal triadrdquo (46 vs 80) survival OR 25

TCCC Order of preference

for fluid resuscitation

bull Fresh whole blood

bull PRBCsFFPPlatelets in 111 ratio

bull PRBCsFFP in 11 ratio

bull PRBCs or FFP

bull Plasmalyte Normosol

bull Lactated Ringers

bull Not recommended Normal Saline

Tranexamic Acid

bull Antithrombolytic

bull ldquoHyperfibrinolysis of traumardquo

bull 1g over 10 min

bull Giving it faster can cause hypotension

bull May give up to 5g (studied up to 250mgkg)

bull Re-dose if hemorrhage is ongoing

Tranexamic Acid

bull CRASH-2 bull Given across a wide spectrum of trauma patients in 40 countries

bull ARR 15

bull Poorly controlled only half went to OR

bull MATTERs bull 17 vs 239 mortality

bull Benefit greatest in those getting MTP

bull MATTERs II bull TXA vs Cryo vs TXA+Cryo

bull 116 vs 236 mortality

bull Best benefit lt1h after injury

bull Some benefit lt3h after injury

bull Possible harm gt3h after injury

Tranexamic Acid

bull CRASH-2 TBI

bull Basically a wash

bull Cole Davenport Brohi TXA did not affect mortality in

overall or non-shock cohorts

bull MVA showed OR of MOF 027 and death 016

bull Valle Allen Higher mortality with TXA if needing gt2L

PRBCs

bull Given 97 min after ADMISSION and after transfusion

Factor VIIa

bull No studies showing mortality benefit

bull Studies showing decreased blood loss

bull $45000dose

bull May consider if still bleeding after TXA

Metabolic acidosis

bull Keep pH above 72

bull Administer THAM (Tromethamine solution) or sodium

bicarbonate to maintain pH

bull Weight in kg x base deficit x 11 = volume of THAM

solution to give (18g500mL)

bull Weight in kg x base deficit x 02 = volume of sodium

bicarb solution to give

Calcium

bull Calcium used up in clots

bull Calcium gobbled up by citrate in stored blood

bull Maintain ionized iCa gt 10 (run on ABG machine)

bull 1g Ca Gluconate for every 4 u FFP

Storage lesions

bull Stored blood is acidic

bull Calcium is chelated by preservatives

bull Platelets decline in function

Thromboelastography

(TEG)

bull Gives a better picture of coagulation status

bull Measures time to initiate clot

bull Speed of formation

bull Strength of clot

bull Fibrinolysis

bull Can help guide transfusion therapy

bull Better outcomes at gt10u PRBCs

bull Fewer units of blood

TEG

TEG Value Transfuse

TEG-ACT gt 140 FFP

R time gt 10 FFP

K time gt 3 Cryo

A angle Cry +- Platelets

MA lt 50 Platelets

LY30 gt3 TXA

REBOA

bull Resuscitative Endovascular Balloon Occlusion of the

Aorta

ER REBOA

Bottom Line

bull Keep them WARM

bull Little to no crystalloid

bull Hypotension is bad for brain injuries

bull Think about MT early

bull 111 ratio

bull Give TXA early

bull Calcium

bull Fix acidosis

bull Balogh Z McKinley BA Cocanour CS Kozar RA Valdivia A Sailors RM Moore FA Supra-normal trauma resuscitation causes more cases of abdominal compartment syndrome Arch Surg 138637-643 2003

bull Duchesne JC Heaney J Guidry C McSwain N Jr Meade P Cohen M Schreiber M Inaba K Skiada D Demetriades D Holcomb J Wade C Cotton B Diluting the benefits of hemostatic resuscitation A multi-institutional analysis J Trauma Acute Care Surg 2013 Jul75(1)76-82 doi 101097TA0b013e3182987df3

bull Guidry C Gleeson E Simms ER Stuke L Meade P McSwain NE Jr Duchesne JC Initial assessment on the impact of crystalloids versus colloids during damage control resuscitation J Surg Res 2013 Jun 15 pii S0022-4804(13)00568-4 doi 101016jjss201305086 [Epub ahead of print]

bull Perel P Roberts I Ker K Colloids versus crystalloids for fluid resuscitation in critically ill patients Cochrane Database Syst Rev 2013 Feb 282CD000567 doi 10100214651858CD000567pub6

bull Zarychanski R Abou-Setta AM Turgeon AF et al Association of Hydroxyethyl Starch Administration With Mortality and Acute Kidney Injury in Critically Ill Patients Requiring Volume Resuscitation A Systematic Review and Meta-analysis JAMA 2013309(7)678-688 doi101001jama2013430

bull Bulger EM May S Kerby JD Emerson S Stiell IG Schreiber MA Brasel KJ Tisherman SA Coimbra R Rizoli S Minei JP Hata JS Sopko G Evans DC Hoyt DB ROC investigators Out-of-hospital hypertonic resuscitation after traumatic hypovolemic shock a randomized placebo controlled trial Ann Surg 2011 Mar253(3)431-41 doi 101097SLA0b013e3181fcdb22

bull Vassar MJ Fischer RP OBrien PE Bachulis BL Chambers JA Hoyt DB Holcroft JW A multicenter trial for resuscitation of injured patients with 75 sodium chloride The effect of added dextran 70 The Multicenter Group for the Study of Hypertonic Saline in Trauma Patients Arch Surg 1993 Sep128(9)1003-11 discussion 1011-3

bull Cooper DJ Myles PS McDermott FT Murray LJ Laidlaw J Cooper G Tremayne AB Bernard SS Ponsford J HTS Study Investigators Prehospital hypertonic saline resuscitation of patients with hypotension and severe traumatic brain injury a randomized controlled trial JAMA 2004 Mar 17291(11)1350-7

bull Duke MD Guidry C Guice J Stuke L Marr AB Hunt JP Meade P McSwain NE Jr Duchesne JC Restrictive fluid resuscitation in combination with damage control resuscitation time for adaptation J Trauma Acute Care Surg 2012 Sep73(3)674-8 doi 101097TA0b013e318265ce1f

bull Pidcoke HF Aden JK Mora AG Borgman MA Spinella PC Dubick MA Blackbourne LH Cap AP Ten-year analysis of transfusion in Operation Iraqi Freedom and Operation Enduring Freedom increased plasma and platelet use correlates with improved survival J Trauma Acute Care Surg 2012 Dec73(6 Suppl 5)S445-52 doi 101097TA0b013e3182754796

bull Morrison CA Carrick MM Norman MA Scott BG Welsh FJ Tsai P Liscum KR Wall MJ Jr Mattox KL Hypotensive resuscitation strategy reduces transfusion requirements and severe postoperative coagulopathy in trauma patients with hemorrhagic shock preliminary results of a randomized controlled trial J Trauma 2011 Mar70(3)652-63 doi 101097TA0b013e31820e77ea

bull Ley EJ Clond MA Srour MK Barnajian M Mirocha J Margulies DR Salim A Emergency department crystalloid resuscitation of 15 L or more is associated with increased mortality in elderly and nonelderly trauma patients J Trauma 2011 Feb70(2)398-400 doi 101097TA0b013e318208f99b

bull Kasotakis G Sideris A Yang Y de Moya M Alam H King DR Tompkins R Velmahos G Inflammation and Host Response to Injury Investigators Aggressive early crystalloid resuscitation adversely affects outcomes in adult blunt trauma patients an analysis of the Glue Grant database J Trauma Acute Care Surg 2013 May74(5)1215-21 discussion 1221-2 doi 101097TA0b013e3182826e13

bull Neal MD Hoffman MK Cuschieri J Minei JP Maier RV Harbrecht BG Billiar TR Peitzman AB Moore EE Cohen MJ Sperry JL Crystalloid to packed red blood cell transfusion ratio in the massively transfused patient when a little goes a long way J Trauma Acute Care Surg 2012 Apr72(4)892-8 doi 101097TA0b013e31823d84a7

bull Niles SE McLaughlin DF Perkins JG et al Increased mortality associated with the early coagulopathy of trauma in combat casualties J Trauma 2008641459-63

bull Brohi K Singh J Heron M Coats T Acute traumatic coagulopathy J Trauma 2003541127-30

bull Cotton BA Gunter OL Isbell J et al Damage control hematology the impact of a trauma exsanguination protocol on survival and blood product utilization J Trauma 2008641177-82

bull Keneally RJ1 Parsons AM1 Willett PB1 Warm fresh whole blood and thoracic traumain iraq and afghanistan J Emerg Trauma Shock 2015 Jan-Mar8(1)21-5

bull Spinella PC1 Perkins JG Grathwohl KW Beekley AC Holcomb JB Warm fresh whole blood is independently associated with improved survival for patients with combat-related traumatic injuries J Trauma 2009 Apr66(4 Suppl)S69-76

bull Wafaisade A1 Lefering R2 Bouillon B3 Boumlhmer AB4 Gaumlszligler M5 Ruppert M5 TraumaRegister DGU Prehospital administration of tranexamic acid in trauma patients Crit Care 2016 May 1220(1)143

bull Ausset S1 Glassberg E Nadler R Sunde G Cap AP Hoffmann C Plang S Sailliol A Tranexamic acid as part of remote damage-control resuscitation in the prehospital setting A critical appraisal of the medical literature and available alternatives J Trauma Acute Care Surg 2015 Jun78(6 Suppl 1)S70-5

bull CRASH-2 trial collaborators Shakur H Roberts I Bautista R Caballero J Coats T Dewan Y El-Sayed H Gogichaishvili T Gupta S Herrera J Hunt B Iribhogbe P Izurieta M Khamis H Komolafe E Marrero MA Mejiacutea-Mantilla J Miranda J Morales C Olaomi O Olldashi F Perel P Peto R Ramana PV Ravi RR Yutthakasemsunt S Effects of tranexamic acid on death vascular occlusive events and blood transfusion in trauma patients with significant haemorrhage (CRASH-2) a randomised placebo-controlled trial Lancet 2010 Jul 3376(9734)23-32

bull Morrison JJ1 Dubose JJ Rasmussen TE Midwinter MJ Military Application of Tranexamic Acid in Trauma Emergency Resuscitation (MATTERs) Study Arch Surg 2012 Feb147(2)113-9

bull Morrison JJ1 Ross JD Dubose JJ Jansen JO Midwinter MJ Rasmussen TE Association of cryoprecipitate and tranexamic acid with improved survival following wartime injury findings from the MATTERs II Study JAMA Surg 2013 Mar148(3)218-25

Solution Na Cl K Ca Mg Lact Acet Gluc

Dex

pH Osm

Plasma 144 107 5 5 15 74 290

09NaCl

ldquonormal salinerdquo

154 154 54 308

Lactated Ringers 130 109 4 3 28 65 273

Normosol 140 98 5 3 27 23 74 295

Plasmalyte A 140 98 5 3 27 23 74 294

Plasmalyte 148 140 98 5 3 27 23 55 294

Hextend 143 124 3 5 09 28 59 307

Hespan 154 154 59 309

Crystalloids in

resuscitation

bull Higher mortality with higher crystalloid volumes in

patients receiving massive transfusion Higher rates of

renal failure too

bull More fluid

bull Volumes gt 15 L of crystalloid = higher mortality

bull Increased ALI ARDS MOSF ICU and hospital LOS

bull Crystalloidblood ratio gt 15L1u associated with higher

mortality and morbidity

Permissive Hypotension

bull Cannon W Fraser J Cowell E The Preventative Treatment of Wound Shock JAMA 1918618-621

bull Poor outcomes with IV fluid resuscitation

bull Forgotten until the 1980s

bull Bickell WH Wall MH Pepe PE Martin RR Ginger VF Allen MK Mattox KL Immediate versus delayed fluid resuscitation for Hypotensive patients with penetrating torso injuries N Engl J Med 1994 Oct 27 3311105-9

bull Maintain SBP 90 mmHg

bull Not good for CNS injuries- linear relationship

Colloids in resuscitation

bull Expensive (20x)

bull No benefit

bull Possible harm death AKI

bull HOWEVER trauma patient cohorts small

bull ldquoThe paper reviewed the use of a variety of hetastarches in a variety of volumes for a variety of indications This study was clearly not designed to answer the question about the risksbenefits of Hextend used in a hypotensive resuscitation strategy for combat casualties when blood products are not available ndash and clearly does not provide that answerrdquo - CoTCCC

Blood Ratios

bull The old LOTS of pRBCs = oxygen carrying capacity

bull The now 111 ratio

bull Replace coagulation factorsplatelets

Blood

bull O- for females at or below CBA

bull O+ for everyone else

bull FFP AB is universal donor

bull A is the next safest

Who Needs Massive

Transfusion

bull Systolic BP lt110

bull HRgt 105

bull Hct lt 32

bull pH lt 725

bull 3 of the 4 70 likelihood

bull 44 85 likelihood

bull INR gt 14 (5x mortality)

bull StO2 lt 75

Who Needs Massive

Transfusion

bull Uncontrolled truncal axillary neck or groin bleeding

bull Uncontrolled bleeding secondary to massive soft tissue

injuries

bull Proximal amputation or mangled extremity

bull Clinical signs of coagulopathy

bull Severe hypothermia with blood loss

Which should we give

first

bull We have decent oxygen carrying capacity when anemic

bull Plasma first transfusion may be better

bull Fix the coagulopathy hypothermia acidosis

bull Prehospital freeze dried plasma (FDP)

bull Being studied by US military

bull Used by our European colleagues

bull not FDA approved in the US currently

Fibrinogen

bull Fresh whole blood 1000 mg of fibrinogen

bull FFP 400 mg

bull Platelets 80 mg

bull Cryoprecipitate 2500 mg

bull Transfusion with high ratios of fibrinogen to RBCs have

shown survival benefit

Fresh Whole Blood

Blood

bull Fresh whole blood AT LEAST equivalent to components

bull May improve survival

bull Restricted fluid resuscitation (lt1500 mL crystalloid) OR

of death 069

bull DCR Less fluid (5 vs 14 L) less pRBCs (7 u vs 13 u)

less ldquolethal triadrdquo (46 vs 80) survival OR 25

TCCC Order of preference

for fluid resuscitation

bull Fresh whole blood

bull PRBCsFFPPlatelets in 111 ratio

bull PRBCsFFP in 11 ratio

bull PRBCs or FFP

bull Plasmalyte Normosol

bull Lactated Ringers

bull Not recommended Normal Saline

Tranexamic Acid

bull Antithrombolytic

bull ldquoHyperfibrinolysis of traumardquo

bull 1g over 10 min

bull Giving it faster can cause hypotension

bull May give up to 5g (studied up to 250mgkg)

bull Re-dose if hemorrhage is ongoing

Tranexamic Acid

bull CRASH-2 bull Given across a wide spectrum of trauma patients in 40 countries

bull ARR 15

bull Poorly controlled only half went to OR

bull MATTERs bull 17 vs 239 mortality

bull Benefit greatest in those getting MTP

bull MATTERs II bull TXA vs Cryo vs TXA+Cryo

bull 116 vs 236 mortality

bull Best benefit lt1h after injury

bull Some benefit lt3h after injury

bull Possible harm gt3h after injury

Tranexamic Acid

bull CRASH-2 TBI

bull Basically a wash

bull Cole Davenport Brohi TXA did not affect mortality in

overall or non-shock cohorts

bull MVA showed OR of MOF 027 and death 016

bull Valle Allen Higher mortality with TXA if needing gt2L

PRBCs

bull Given 97 min after ADMISSION and after transfusion

Factor VIIa

bull No studies showing mortality benefit

bull Studies showing decreased blood loss

bull $45000dose

bull May consider if still bleeding after TXA

Metabolic acidosis

bull Keep pH above 72

bull Administer THAM (Tromethamine solution) or sodium

bicarbonate to maintain pH

bull Weight in kg x base deficit x 11 = volume of THAM

solution to give (18g500mL)

bull Weight in kg x base deficit x 02 = volume of sodium

bicarb solution to give

Calcium

bull Calcium used up in clots

bull Calcium gobbled up by citrate in stored blood

bull Maintain ionized iCa gt 10 (run on ABG machine)

bull 1g Ca Gluconate for every 4 u FFP

Storage lesions

bull Stored blood is acidic

bull Calcium is chelated by preservatives

bull Platelets decline in function

Thromboelastography

(TEG)

bull Gives a better picture of coagulation status

bull Measures time to initiate clot

bull Speed of formation

bull Strength of clot

bull Fibrinolysis

bull Can help guide transfusion therapy

bull Better outcomes at gt10u PRBCs

bull Fewer units of blood

TEG

TEG Value Transfuse

TEG-ACT gt 140 FFP

R time gt 10 FFP

K time gt 3 Cryo

A angle Cry +- Platelets

MA lt 50 Platelets

LY30 gt3 TXA

REBOA

bull Resuscitative Endovascular Balloon Occlusion of the

Aorta

ER REBOA

Bottom Line

bull Keep them WARM

bull Little to no crystalloid

bull Hypotension is bad for brain injuries

bull Think about MT early

bull 111 ratio

bull Give TXA early

bull Calcium

bull Fix acidosis

bull Balogh Z McKinley BA Cocanour CS Kozar RA Valdivia A Sailors RM Moore FA Supra-normal trauma resuscitation causes more cases of abdominal compartment syndrome Arch Surg 138637-643 2003

bull Duchesne JC Heaney J Guidry C McSwain N Jr Meade P Cohen M Schreiber M Inaba K Skiada D Demetriades D Holcomb J Wade C Cotton B Diluting the benefits of hemostatic resuscitation A multi-institutional analysis J Trauma Acute Care Surg 2013 Jul75(1)76-82 doi 101097TA0b013e3182987df3

bull Guidry C Gleeson E Simms ER Stuke L Meade P McSwain NE Jr Duchesne JC Initial assessment on the impact of crystalloids versus colloids during damage control resuscitation J Surg Res 2013 Jun 15 pii S0022-4804(13)00568-4 doi 101016jjss201305086 [Epub ahead of print]

bull Perel P Roberts I Ker K Colloids versus crystalloids for fluid resuscitation in critically ill patients Cochrane Database Syst Rev 2013 Feb 282CD000567 doi 10100214651858CD000567pub6

bull Zarychanski R Abou-Setta AM Turgeon AF et al Association of Hydroxyethyl Starch Administration With Mortality and Acute Kidney Injury in Critically Ill Patients Requiring Volume Resuscitation A Systematic Review and Meta-analysis JAMA 2013309(7)678-688 doi101001jama2013430

bull Bulger EM May S Kerby JD Emerson S Stiell IG Schreiber MA Brasel KJ Tisherman SA Coimbra R Rizoli S Minei JP Hata JS Sopko G Evans DC Hoyt DB ROC investigators Out-of-hospital hypertonic resuscitation after traumatic hypovolemic shock a randomized placebo controlled trial Ann Surg 2011 Mar253(3)431-41 doi 101097SLA0b013e3181fcdb22

bull Vassar MJ Fischer RP OBrien PE Bachulis BL Chambers JA Hoyt DB Holcroft JW A multicenter trial for resuscitation of injured patients with 75 sodium chloride The effect of added dextran 70 The Multicenter Group for the Study of Hypertonic Saline in Trauma Patients Arch Surg 1993 Sep128(9)1003-11 discussion 1011-3

bull Cooper DJ Myles PS McDermott FT Murray LJ Laidlaw J Cooper G Tremayne AB Bernard SS Ponsford J HTS Study Investigators Prehospital hypertonic saline resuscitation of patients with hypotension and severe traumatic brain injury a randomized controlled trial JAMA 2004 Mar 17291(11)1350-7

bull Duke MD Guidry C Guice J Stuke L Marr AB Hunt JP Meade P McSwain NE Jr Duchesne JC Restrictive fluid resuscitation in combination with damage control resuscitation time for adaptation J Trauma Acute Care Surg 2012 Sep73(3)674-8 doi 101097TA0b013e318265ce1f

bull Pidcoke HF Aden JK Mora AG Borgman MA Spinella PC Dubick MA Blackbourne LH Cap AP Ten-year analysis of transfusion in Operation Iraqi Freedom and Operation Enduring Freedom increased plasma and platelet use correlates with improved survival J Trauma Acute Care Surg 2012 Dec73(6 Suppl 5)S445-52 doi 101097TA0b013e3182754796

bull Morrison CA Carrick MM Norman MA Scott BG Welsh FJ Tsai P Liscum KR Wall MJ Jr Mattox KL Hypotensive resuscitation strategy reduces transfusion requirements and severe postoperative coagulopathy in trauma patients with hemorrhagic shock preliminary results of a randomized controlled trial J Trauma 2011 Mar70(3)652-63 doi 101097TA0b013e31820e77ea

bull Ley EJ Clond MA Srour MK Barnajian M Mirocha J Margulies DR Salim A Emergency department crystalloid resuscitation of 15 L or more is associated with increased mortality in elderly and nonelderly trauma patients J Trauma 2011 Feb70(2)398-400 doi 101097TA0b013e318208f99b

bull Kasotakis G Sideris A Yang Y de Moya M Alam H King DR Tompkins R Velmahos G Inflammation and Host Response to Injury Investigators Aggressive early crystalloid resuscitation adversely affects outcomes in adult blunt trauma patients an analysis of the Glue Grant database J Trauma Acute Care Surg 2013 May74(5)1215-21 discussion 1221-2 doi 101097TA0b013e3182826e13

bull Neal MD Hoffman MK Cuschieri J Minei JP Maier RV Harbrecht BG Billiar TR Peitzman AB Moore EE Cohen MJ Sperry JL Crystalloid to packed red blood cell transfusion ratio in the massively transfused patient when a little goes a long way J Trauma Acute Care Surg 2012 Apr72(4)892-8 doi 101097TA0b013e31823d84a7

bull Niles SE McLaughlin DF Perkins JG et al Increased mortality associated with the early coagulopathy of trauma in combat casualties J Trauma 2008641459-63

bull Brohi K Singh J Heron M Coats T Acute traumatic coagulopathy J Trauma 2003541127-30

bull Cotton BA Gunter OL Isbell J et al Damage control hematology the impact of a trauma exsanguination protocol on survival and blood product utilization J Trauma 2008641177-82

bull Keneally RJ1 Parsons AM1 Willett PB1 Warm fresh whole blood and thoracic traumain iraq and afghanistan J Emerg Trauma Shock 2015 Jan-Mar8(1)21-5

bull Spinella PC1 Perkins JG Grathwohl KW Beekley AC Holcomb JB Warm fresh whole blood is independently associated with improved survival for patients with combat-related traumatic injuries J Trauma 2009 Apr66(4 Suppl)S69-76

bull Wafaisade A1 Lefering R2 Bouillon B3 Boumlhmer AB4 Gaumlszligler M5 Ruppert M5 TraumaRegister DGU Prehospital administration of tranexamic acid in trauma patients Crit Care 2016 May 1220(1)143

bull Ausset S1 Glassberg E Nadler R Sunde G Cap AP Hoffmann C Plang S Sailliol A Tranexamic acid as part of remote damage-control resuscitation in the prehospital setting A critical appraisal of the medical literature and available alternatives J Trauma Acute Care Surg 2015 Jun78(6 Suppl 1)S70-5

bull CRASH-2 trial collaborators Shakur H Roberts I Bautista R Caballero J Coats T Dewan Y El-Sayed H Gogichaishvili T Gupta S Herrera J Hunt B Iribhogbe P Izurieta M Khamis H Komolafe E Marrero MA Mejiacutea-Mantilla J Miranda J Morales C Olaomi O Olldashi F Perel P Peto R Ramana PV Ravi RR Yutthakasemsunt S Effects of tranexamic acid on death vascular occlusive events and blood transfusion in trauma patients with significant haemorrhage (CRASH-2) a randomised placebo-controlled trial Lancet 2010 Jul 3376(9734)23-32

bull Morrison JJ1 Dubose JJ Rasmussen TE Midwinter MJ Military Application of Tranexamic Acid in Trauma Emergency Resuscitation (MATTERs) Study Arch Surg 2012 Feb147(2)113-9

bull Morrison JJ1 Ross JD Dubose JJ Jansen JO Midwinter MJ Rasmussen TE Association of cryoprecipitate and tranexamic acid with improved survival following wartime injury findings from the MATTERs II Study JAMA Surg 2013 Mar148(3)218-25

Crystalloids in

resuscitation

bull Higher mortality with higher crystalloid volumes in

patients receiving massive transfusion Higher rates of

renal failure too

bull More fluid

bull Volumes gt 15 L of crystalloid = higher mortality

bull Increased ALI ARDS MOSF ICU and hospital LOS

bull Crystalloidblood ratio gt 15L1u associated with higher

mortality and morbidity

Permissive Hypotension

bull Cannon W Fraser J Cowell E The Preventative Treatment of Wound Shock JAMA 1918618-621

bull Poor outcomes with IV fluid resuscitation

bull Forgotten until the 1980s

bull Bickell WH Wall MH Pepe PE Martin RR Ginger VF Allen MK Mattox KL Immediate versus delayed fluid resuscitation for Hypotensive patients with penetrating torso injuries N Engl J Med 1994 Oct 27 3311105-9

bull Maintain SBP 90 mmHg

bull Not good for CNS injuries- linear relationship

Colloids in resuscitation

bull Expensive (20x)

bull No benefit

bull Possible harm death AKI

bull HOWEVER trauma patient cohorts small

bull ldquoThe paper reviewed the use of a variety of hetastarches in a variety of volumes for a variety of indications This study was clearly not designed to answer the question about the risksbenefits of Hextend used in a hypotensive resuscitation strategy for combat casualties when blood products are not available ndash and clearly does not provide that answerrdquo - CoTCCC

Blood Ratios

bull The old LOTS of pRBCs = oxygen carrying capacity

bull The now 111 ratio

bull Replace coagulation factorsplatelets

Blood

bull O- for females at or below CBA

bull O+ for everyone else

bull FFP AB is universal donor

bull A is the next safest

Who Needs Massive

Transfusion

bull Systolic BP lt110

bull HRgt 105

bull Hct lt 32

bull pH lt 725

bull 3 of the 4 70 likelihood

bull 44 85 likelihood

bull INR gt 14 (5x mortality)

bull StO2 lt 75

Who Needs Massive

Transfusion

bull Uncontrolled truncal axillary neck or groin bleeding

bull Uncontrolled bleeding secondary to massive soft tissue

injuries

bull Proximal amputation or mangled extremity

bull Clinical signs of coagulopathy

bull Severe hypothermia with blood loss

Which should we give

first

bull We have decent oxygen carrying capacity when anemic

bull Plasma first transfusion may be better

bull Fix the coagulopathy hypothermia acidosis

bull Prehospital freeze dried plasma (FDP)

bull Being studied by US military

bull Used by our European colleagues

bull not FDA approved in the US currently

Fibrinogen

bull Fresh whole blood 1000 mg of fibrinogen

bull FFP 400 mg

bull Platelets 80 mg

bull Cryoprecipitate 2500 mg

bull Transfusion with high ratios of fibrinogen to RBCs have

shown survival benefit

Fresh Whole Blood

Blood

bull Fresh whole blood AT LEAST equivalent to components

bull May improve survival

bull Restricted fluid resuscitation (lt1500 mL crystalloid) OR

of death 069

bull DCR Less fluid (5 vs 14 L) less pRBCs (7 u vs 13 u)

less ldquolethal triadrdquo (46 vs 80) survival OR 25

TCCC Order of preference

for fluid resuscitation

bull Fresh whole blood

bull PRBCsFFPPlatelets in 111 ratio

bull PRBCsFFP in 11 ratio

bull PRBCs or FFP

bull Plasmalyte Normosol

bull Lactated Ringers

bull Not recommended Normal Saline

Tranexamic Acid

bull Antithrombolytic

bull ldquoHyperfibrinolysis of traumardquo

bull 1g over 10 min

bull Giving it faster can cause hypotension

bull May give up to 5g (studied up to 250mgkg)

bull Re-dose if hemorrhage is ongoing

Tranexamic Acid

bull CRASH-2 bull Given across a wide spectrum of trauma patients in 40 countries

bull ARR 15

bull Poorly controlled only half went to OR

bull MATTERs bull 17 vs 239 mortality

bull Benefit greatest in those getting MTP

bull MATTERs II bull TXA vs Cryo vs TXA+Cryo

bull 116 vs 236 mortality

bull Best benefit lt1h after injury

bull Some benefit lt3h after injury

bull Possible harm gt3h after injury

Tranexamic Acid

bull CRASH-2 TBI

bull Basically a wash

bull Cole Davenport Brohi TXA did not affect mortality in

overall or non-shock cohorts

bull MVA showed OR of MOF 027 and death 016

bull Valle Allen Higher mortality with TXA if needing gt2L

PRBCs

bull Given 97 min after ADMISSION and after transfusion

Factor VIIa

bull No studies showing mortality benefit

bull Studies showing decreased blood loss

bull $45000dose

bull May consider if still bleeding after TXA

Metabolic acidosis

bull Keep pH above 72

bull Administer THAM (Tromethamine solution) or sodium

bicarbonate to maintain pH

bull Weight in kg x base deficit x 11 = volume of THAM

solution to give (18g500mL)

bull Weight in kg x base deficit x 02 = volume of sodium

bicarb solution to give

Calcium

bull Calcium used up in clots

bull Calcium gobbled up by citrate in stored blood

bull Maintain ionized iCa gt 10 (run on ABG machine)

bull 1g Ca Gluconate for every 4 u FFP

Storage lesions

bull Stored blood is acidic

bull Calcium is chelated by preservatives

bull Platelets decline in function

Thromboelastography

(TEG)

bull Gives a better picture of coagulation status

bull Measures time to initiate clot

bull Speed of formation

bull Strength of clot

bull Fibrinolysis

bull Can help guide transfusion therapy

bull Better outcomes at gt10u PRBCs

bull Fewer units of blood

TEG

TEG Value Transfuse

TEG-ACT gt 140 FFP

R time gt 10 FFP

K time gt 3 Cryo

A angle Cry +- Platelets

MA lt 50 Platelets

LY30 gt3 TXA

REBOA

bull Resuscitative Endovascular Balloon Occlusion of the

Aorta

ER REBOA

Bottom Line

bull Keep them WARM

bull Little to no crystalloid

bull Hypotension is bad for brain injuries

bull Think about MT early

bull 111 ratio

bull Give TXA early

bull Calcium

bull Fix acidosis

bull Balogh Z McKinley BA Cocanour CS Kozar RA Valdivia A Sailors RM Moore FA Supra-normal trauma resuscitation causes more cases of abdominal compartment syndrome Arch Surg 138637-643 2003

bull Duchesne JC Heaney J Guidry C McSwain N Jr Meade P Cohen M Schreiber M Inaba K Skiada D Demetriades D Holcomb J Wade C Cotton B Diluting the benefits of hemostatic resuscitation A multi-institutional analysis J Trauma Acute Care Surg 2013 Jul75(1)76-82 doi 101097TA0b013e3182987df3

bull Guidry C Gleeson E Simms ER Stuke L Meade P McSwain NE Jr Duchesne JC Initial assessment on the impact of crystalloids versus colloids during damage control resuscitation J Surg Res 2013 Jun 15 pii S0022-4804(13)00568-4 doi 101016jjss201305086 [Epub ahead of print]

bull Perel P Roberts I Ker K Colloids versus crystalloids for fluid resuscitation in critically ill patients Cochrane Database Syst Rev 2013 Feb 282CD000567 doi 10100214651858CD000567pub6

bull Zarychanski R Abou-Setta AM Turgeon AF et al Association of Hydroxyethyl Starch Administration With Mortality and Acute Kidney Injury in Critically Ill Patients Requiring Volume Resuscitation A Systematic Review and Meta-analysis JAMA 2013309(7)678-688 doi101001jama2013430

bull Bulger EM May S Kerby JD Emerson S Stiell IG Schreiber MA Brasel KJ Tisherman SA Coimbra R Rizoli S Minei JP Hata JS Sopko G Evans DC Hoyt DB ROC investigators Out-of-hospital hypertonic resuscitation after traumatic hypovolemic shock a randomized placebo controlled trial Ann Surg 2011 Mar253(3)431-41 doi 101097SLA0b013e3181fcdb22

bull Vassar MJ Fischer RP OBrien PE Bachulis BL Chambers JA Hoyt DB Holcroft JW A multicenter trial for resuscitation of injured patients with 75 sodium chloride The effect of added dextran 70 The Multicenter Group for the Study of Hypertonic Saline in Trauma Patients Arch Surg 1993 Sep128(9)1003-11 discussion 1011-3

bull Cooper DJ Myles PS McDermott FT Murray LJ Laidlaw J Cooper G Tremayne AB Bernard SS Ponsford J HTS Study Investigators Prehospital hypertonic saline resuscitation of patients with hypotension and severe traumatic brain injury a randomized controlled trial JAMA 2004 Mar 17291(11)1350-7

bull Duke MD Guidry C Guice J Stuke L Marr AB Hunt JP Meade P McSwain NE Jr Duchesne JC Restrictive fluid resuscitation in combination with damage control resuscitation time for adaptation J Trauma Acute Care Surg 2012 Sep73(3)674-8 doi 101097TA0b013e318265ce1f

bull Pidcoke HF Aden JK Mora AG Borgman MA Spinella PC Dubick MA Blackbourne LH Cap AP Ten-year analysis of transfusion in Operation Iraqi Freedom and Operation Enduring Freedom increased plasma and platelet use correlates with improved survival J Trauma Acute Care Surg 2012 Dec73(6 Suppl 5)S445-52 doi 101097TA0b013e3182754796

bull Morrison CA Carrick MM Norman MA Scott BG Welsh FJ Tsai P Liscum KR Wall MJ Jr Mattox KL Hypotensive resuscitation strategy reduces transfusion requirements and severe postoperative coagulopathy in trauma patients with hemorrhagic shock preliminary results of a randomized controlled trial J Trauma 2011 Mar70(3)652-63 doi 101097TA0b013e31820e77ea

bull Ley EJ Clond MA Srour MK Barnajian M Mirocha J Margulies DR Salim A Emergency department crystalloid resuscitation of 15 L or more is associated with increased mortality in elderly and nonelderly trauma patients J Trauma 2011 Feb70(2)398-400 doi 101097TA0b013e318208f99b

bull Kasotakis G Sideris A Yang Y de Moya M Alam H King DR Tompkins R Velmahos G Inflammation and Host Response to Injury Investigators Aggressive early crystalloid resuscitation adversely affects outcomes in adult blunt trauma patients an analysis of the Glue Grant database J Trauma Acute Care Surg 2013 May74(5)1215-21 discussion 1221-2 doi 101097TA0b013e3182826e13

bull Neal MD Hoffman MK Cuschieri J Minei JP Maier RV Harbrecht BG Billiar TR Peitzman AB Moore EE Cohen MJ Sperry JL Crystalloid to packed red blood cell transfusion ratio in the massively transfused patient when a little goes a long way J Trauma Acute Care Surg 2012 Apr72(4)892-8 doi 101097TA0b013e31823d84a7

bull Niles SE McLaughlin DF Perkins JG et al Increased mortality associated with the early coagulopathy of trauma in combat casualties J Trauma 2008641459-63

bull Brohi K Singh J Heron M Coats T Acute traumatic coagulopathy J Trauma 2003541127-30

bull Cotton BA Gunter OL Isbell J et al Damage control hematology the impact of a trauma exsanguination protocol on survival and blood product utilization J Trauma 2008641177-82

bull Keneally RJ1 Parsons AM1 Willett PB1 Warm fresh whole blood and thoracic traumain iraq and afghanistan J Emerg Trauma Shock 2015 Jan-Mar8(1)21-5

bull Spinella PC1 Perkins JG Grathwohl KW Beekley AC Holcomb JB Warm fresh whole blood is independently associated with improved survival for patients with combat-related traumatic injuries J Trauma 2009 Apr66(4 Suppl)S69-76

bull Wafaisade A1 Lefering R2 Bouillon B3 Boumlhmer AB4 Gaumlszligler M5 Ruppert M5 TraumaRegister DGU Prehospital administration of tranexamic acid in trauma patients Crit Care 2016 May 1220(1)143

bull Ausset S1 Glassberg E Nadler R Sunde G Cap AP Hoffmann C Plang S Sailliol A Tranexamic acid as part of remote damage-control resuscitation in the prehospital setting A critical appraisal of the medical literature and available alternatives J Trauma Acute Care Surg 2015 Jun78(6 Suppl 1)S70-5

bull CRASH-2 trial collaborators Shakur H Roberts I Bautista R Caballero J Coats T Dewan Y El-Sayed H Gogichaishvili T Gupta S Herrera J Hunt B Iribhogbe P Izurieta M Khamis H Komolafe E Marrero MA Mejiacutea-Mantilla J Miranda J Morales C Olaomi O Olldashi F Perel P Peto R Ramana PV Ravi RR Yutthakasemsunt S Effects of tranexamic acid on death vascular occlusive events and blood transfusion in trauma patients with significant haemorrhage (CRASH-2) a randomised placebo-controlled trial Lancet 2010 Jul 3376(9734)23-32

bull Morrison JJ1 Dubose JJ Rasmussen TE Midwinter MJ Military Application of Tranexamic Acid in Trauma Emergency Resuscitation (MATTERs) Study Arch Surg 2012 Feb147(2)113-9

bull Morrison JJ1 Ross JD Dubose JJ Jansen JO Midwinter MJ Rasmussen TE Association of cryoprecipitate and tranexamic acid with improved survival following wartime injury findings from the MATTERs II Study JAMA Surg 2013 Mar148(3)218-25

Permissive Hypotension

bull Cannon W Fraser J Cowell E The Preventative Treatment of Wound Shock JAMA 1918618-621

bull Poor outcomes with IV fluid resuscitation

bull Forgotten until the 1980s

bull Bickell WH Wall MH Pepe PE Martin RR Ginger VF Allen MK Mattox KL Immediate versus delayed fluid resuscitation for Hypotensive patients with penetrating torso injuries N Engl J Med 1994 Oct 27 3311105-9

bull Maintain SBP 90 mmHg

bull Not good for CNS injuries- linear relationship

Colloids in resuscitation

bull Expensive (20x)

bull No benefit

bull Possible harm death AKI

bull HOWEVER trauma patient cohorts small

bull ldquoThe paper reviewed the use of a variety of hetastarches in a variety of volumes for a variety of indications This study was clearly not designed to answer the question about the risksbenefits of Hextend used in a hypotensive resuscitation strategy for combat casualties when blood products are not available ndash and clearly does not provide that answerrdquo - CoTCCC

Blood Ratios

bull The old LOTS of pRBCs = oxygen carrying capacity

bull The now 111 ratio

bull Replace coagulation factorsplatelets

Blood

bull O- for females at or below CBA

bull O+ for everyone else

bull FFP AB is universal donor

bull A is the next safest

Who Needs Massive

Transfusion

bull Systolic BP lt110

bull HRgt 105

bull Hct lt 32

bull pH lt 725

bull 3 of the 4 70 likelihood

bull 44 85 likelihood

bull INR gt 14 (5x mortality)

bull StO2 lt 75

Who Needs Massive

Transfusion

bull Uncontrolled truncal axillary neck or groin bleeding

bull Uncontrolled bleeding secondary to massive soft tissue

injuries

bull Proximal amputation or mangled extremity

bull Clinical signs of coagulopathy

bull Severe hypothermia with blood loss

Which should we give

first

bull We have decent oxygen carrying capacity when anemic

bull Plasma first transfusion may be better

bull Fix the coagulopathy hypothermia acidosis

bull Prehospital freeze dried plasma (FDP)

bull Being studied by US military

bull Used by our European colleagues

bull not FDA approved in the US currently

Fibrinogen

bull Fresh whole blood 1000 mg of fibrinogen

bull FFP 400 mg

bull Platelets 80 mg

bull Cryoprecipitate 2500 mg

bull Transfusion with high ratios of fibrinogen to RBCs have

shown survival benefit

Fresh Whole Blood

Blood

bull Fresh whole blood AT LEAST equivalent to components

bull May improve survival

bull Restricted fluid resuscitation (lt1500 mL crystalloid) OR

of death 069

bull DCR Less fluid (5 vs 14 L) less pRBCs (7 u vs 13 u)

less ldquolethal triadrdquo (46 vs 80) survival OR 25

TCCC Order of preference

for fluid resuscitation

bull Fresh whole blood

bull PRBCsFFPPlatelets in 111 ratio

bull PRBCsFFP in 11 ratio

bull PRBCs or FFP

bull Plasmalyte Normosol

bull Lactated Ringers

bull Not recommended Normal Saline

Tranexamic Acid

bull Antithrombolytic

bull ldquoHyperfibrinolysis of traumardquo

bull 1g over 10 min

bull Giving it faster can cause hypotension

bull May give up to 5g (studied up to 250mgkg)

bull Re-dose if hemorrhage is ongoing

Tranexamic Acid

bull CRASH-2 bull Given across a wide spectrum of trauma patients in 40 countries

bull ARR 15

bull Poorly controlled only half went to OR

bull MATTERs bull 17 vs 239 mortality

bull Benefit greatest in those getting MTP

bull MATTERs II bull TXA vs Cryo vs TXA+Cryo

bull 116 vs 236 mortality

bull Best benefit lt1h after injury

bull Some benefit lt3h after injury

bull Possible harm gt3h after injury

Tranexamic Acid

bull CRASH-2 TBI

bull Basically a wash

bull Cole Davenport Brohi TXA did not affect mortality in

overall or non-shock cohorts

bull MVA showed OR of MOF 027 and death 016

bull Valle Allen Higher mortality with TXA if needing gt2L

PRBCs

bull Given 97 min after ADMISSION and after transfusion

Factor VIIa

bull No studies showing mortality benefit

bull Studies showing decreased blood loss

bull $45000dose

bull May consider if still bleeding after TXA

Metabolic acidosis

bull Keep pH above 72

bull Administer THAM (Tromethamine solution) or sodium

bicarbonate to maintain pH

bull Weight in kg x base deficit x 11 = volume of THAM

solution to give (18g500mL)

bull Weight in kg x base deficit x 02 = volume of sodium

bicarb solution to give

Calcium

bull Calcium used up in clots

bull Calcium gobbled up by citrate in stored blood

bull Maintain ionized iCa gt 10 (run on ABG machine)

bull 1g Ca Gluconate for every 4 u FFP

Storage lesions

bull Stored blood is acidic

bull Calcium is chelated by preservatives

bull Platelets decline in function

Thromboelastography

(TEG)

bull Gives a better picture of coagulation status

bull Measures time to initiate clot

bull Speed of formation

bull Strength of clot

bull Fibrinolysis

bull Can help guide transfusion therapy

bull Better outcomes at gt10u PRBCs

bull Fewer units of blood

TEG

TEG Value Transfuse

TEG-ACT gt 140 FFP

R time gt 10 FFP

K time gt 3 Cryo

A angle Cry +- Platelets

MA lt 50 Platelets

LY30 gt3 TXA

REBOA

bull Resuscitative Endovascular Balloon Occlusion of the

Aorta

ER REBOA

Bottom Line

bull Keep them WARM

bull Little to no crystalloid

bull Hypotension is bad for brain injuries

bull Think about MT early

bull 111 ratio

bull Give TXA early

bull Calcium

bull Fix acidosis

bull Balogh Z McKinley BA Cocanour CS Kozar RA Valdivia A Sailors RM Moore FA Supra-normal trauma resuscitation causes more cases of abdominal compartment syndrome Arch Surg 138637-643 2003

bull Duchesne JC Heaney J Guidry C McSwain N Jr Meade P Cohen M Schreiber M Inaba K Skiada D Demetriades D Holcomb J Wade C Cotton B Diluting the benefits of hemostatic resuscitation A multi-institutional analysis J Trauma Acute Care Surg 2013 Jul75(1)76-82 doi 101097TA0b013e3182987df3

bull Guidry C Gleeson E Simms ER Stuke L Meade P McSwain NE Jr Duchesne JC Initial assessment on the impact of crystalloids versus colloids during damage control resuscitation J Surg Res 2013 Jun 15 pii S0022-4804(13)00568-4 doi 101016jjss201305086 [Epub ahead of print]

bull Perel P Roberts I Ker K Colloids versus crystalloids for fluid resuscitation in critically ill patients Cochrane Database Syst Rev 2013 Feb 282CD000567 doi 10100214651858CD000567pub6

bull Zarychanski R Abou-Setta AM Turgeon AF et al Association of Hydroxyethyl Starch Administration With Mortality and Acute Kidney Injury in Critically Ill Patients Requiring Volume Resuscitation A Systematic Review and Meta-analysis JAMA 2013309(7)678-688 doi101001jama2013430

bull Bulger EM May S Kerby JD Emerson S Stiell IG Schreiber MA Brasel KJ Tisherman SA Coimbra R Rizoli S Minei JP Hata JS Sopko G Evans DC Hoyt DB ROC investigators Out-of-hospital hypertonic resuscitation after traumatic hypovolemic shock a randomized placebo controlled trial Ann Surg 2011 Mar253(3)431-41 doi 101097SLA0b013e3181fcdb22

bull Vassar MJ Fischer RP OBrien PE Bachulis BL Chambers JA Hoyt DB Holcroft JW A multicenter trial for resuscitation of injured patients with 75 sodium chloride The effect of added dextran 70 The Multicenter Group for the Study of Hypertonic Saline in Trauma Patients Arch Surg 1993 Sep128(9)1003-11 discussion 1011-3

bull Cooper DJ Myles PS McDermott FT Murray LJ Laidlaw J Cooper G Tremayne AB Bernard SS Ponsford J HTS Study Investigators Prehospital hypertonic saline resuscitation of patients with hypotension and severe traumatic brain injury a randomized controlled trial JAMA 2004 Mar 17291(11)1350-7

bull Duke MD Guidry C Guice J Stuke L Marr AB Hunt JP Meade P McSwain NE Jr Duchesne JC Restrictive fluid resuscitation in combination with damage control resuscitation time for adaptation J Trauma Acute Care Surg 2012 Sep73(3)674-8 doi 101097TA0b013e318265ce1f

bull Pidcoke HF Aden JK Mora AG Borgman MA Spinella PC Dubick MA Blackbourne LH Cap AP Ten-year analysis of transfusion in Operation Iraqi Freedom and Operation Enduring Freedom increased plasma and platelet use correlates with improved survival J Trauma Acute Care Surg 2012 Dec73(6 Suppl 5)S445-52 doi 101097TA0b013e3182754796

bull Morrison CA Carrick MM Norman MA Scott BG Welsh FJ Tsai P Liscum KR Wall MJ Jr Mattox KL Hypotensive resuscitation strategy reduces transfusion requirements and severe postoperative coagulopathy in trauma patients with hemorrhagic shock preliminary results of a randomized controlled trial J Trauma 2011 Mar70(3)652-63 doi 101097TA0b013e31820e77ea

bull Ley EJ Clond MA Srour MK Barnajian M Mirocha J Margulies DR Salim A Emergency department crystalloid resuscitation of 15 L or more is associated with increased mortality in elderly and nonelderly trauma patients J Trauma 2011 Feb70(2)398-400 doi 101097TA0b013e318208f99b

bull Kasotakis G Sideris A Yang Y de Moya M Alam H King DR Tompkins R Velmahos G Inflammation and Host Response to Injury Investigators Aggressive early crystalloid resuscitation adversely affects outcomes in adult blunt trauma patients an analysis of the Glue Grant database J Trauma Acute Care Surg 2013 May74(5)1215-21 discussion 1221-2 doi 101097TA0b013e3182826e13

bull Neal MD Hoffman MK Cuschieri J Minei JP Maier RV Harbrecht BG Billiar TR Peitzman AB Moore EE Cohen MJ Sperry JL Crystalloid to packed red blood cell transfusion ratio in the massively transfused patient when a little goes a long way J Trauma Acute Care Surg 2012 Apr72(4)892-8 doi 101097TA0b013e31823d84a7

bull Niles SE McLaughlin DF Perkins JG et al Increased mortality associated with the early coagulopathy of trauma in combat casualties J Trauma 2008641459-63

bull Brohi K Singh J Heron M Coats T Acute traumatic coagulopathy J Trauma 2003541127-30

bull Cotton BA Gunter OL Isbell J et al Damage control hematology the impact of a trauma exsanguination protocol on survival and blood product utilization J Trauma 2008641177-82

bull Keneally RJ1 Parsons AM1 Willett PB1 Warm fresh whole blood and thoracic traumain iraq and afghanistan J Emerg Trauma Shock 2015 Jan-Mar8(1)21-5

bull Spinella PC1 Perkins JG Grathwohl KW Beekley AC Holcomb JB Warm fresh whole blood is independently associated with improved survival for patients with combat-related traumatic injuries J Trauma 2009 Apr66(4 Suppl)S69-76

bull Wafaisade A1 Lefering R2 Bouillon B3 Boumlhmer AB4 Gaumlszligler M5 Ruppert M5 TraumaRegister DGU Prehospital administration of tranexamic acid in trauma patients Crit Care 2016 May 1220(1)143

bull Ausset S1 Glassberg E Nadler R Sunde G Cap AP Hoffmann C Plang S Sailliol A Tranexamic acid as part of remote damage-control resuscitation in the prehospital setting A critical appraisal of the medical literature and available alternatives J Trauma Acute Care Surg 2015 Jun78(6 Suppl 1)S70-5

bull CRASH-2 trial collaborators Shakur H Roberts I Bautista R Caballero J Coats T Dewan Y El-Sayed H Gogichaishvili T Gupta S Herrera J Hunt B Iribhogbe P Izurieta M Khamis H Komolafe E Marrero MA Mejiacutea-Mantilla J Miranda J Morales C Olaomi O Olldashi F Perel P Peto R Ramana PV Ravi RR Yutthakasemsunt S Effects of tranexamic acid on death vascular occlusive events and blood transfusion in trauma patients with significant haemorrhage (CRASH-2) a randomised placebo-controlled trial Lancet 2010 Jul 3376(9734)23-32

bull Morrison JJ1 Dubose JJ Rasmussen TE Midwinter MJ Military Application of Tranexamic Acid in Trauma Emergency Resuscitation (MATTERs) Study Arch Surg 2012 Feb147(2)113-9

bull Morrison JJ1 Ross JD Dubose JJ Jansen JO Midwinter MJ Rasmussen TE Association of cryoprecipitate and tranexamic acid with improved survival following wartime injury findings from the MATTERs II Study JAMA Surg 2013 Mar148(3)218-25

Colloids in resuscitation

bull Expensive (20x)

bull No benefit

bull Possible harm death AKI

bull HOWEVER trauma patient cohorts small

bull ldquoThe paper reviewed the use of a variety of hetastarches in a variety of volumes for a variety of indications This study was clearly not designed to answer the question about the risksbenefits of Hextend used in a hypotensive resuscitation strategy for combat casualties when blood products are not available ndash and clearly does not provide that answerrdquo - CoTCCC

Blood Ratios

bull The old LOTS of pRBCs = oxygen carrying capacity

bull The now 111 ratio

bull Replace coagulation factorsplatelets

Blood

bull O- for females at or below CBA

bull O+ for everyone else

bull FFP AB is universal donor

bull A is the next safest

Who Needs Massive

Transfusion

bull Systolic BP lt110

bull HRgt 105

bull Hct lt 32

bull pH lt 725

bull 3 of the 4 70 likelihood

bull 44 85 likelihood

bull INR gt 14 (5x mortality)

bull StO2 lt 75

Who Needs Massive

Transfusion

bull Uncontrolled truncal axillary neck or groin bleeding

bull Uncontrolled bleeding secondary to massive soft tissue

injuries

bull Proximal amputation or mangled extremity

bull Clinical signs of coagulopathy

bull Severe hypothermia with blood loss

Which should we give

first

bull We have decent oxygen carrying capacity when anemic

bull Plasma first transfusion may be better

bull Fix the coagulopathy hypothermia acidosis

bull Prehospital freeze dried plasma (FDP)

bull Being studied by US military

bull Used by our European colleagues

bull not FDA approved in the US currently

Fibrinogen

bull Fresh whole blood 1000 mg of fibrinogen

bull FFP 400 mg

bull Platelets 80 mg

bull Cryoprecipitate 2500 mg

bull Transfusion with high ratios of fibrinogen to RBCs have

shown survival benefit

Fresh Whole Blood

Blood

bull Fresh whole blood AT LEAST equivalent to components

bull May improve survival

bull Restricted fluid resuscitation (lt1500 mL crystalloid) OR

of death 069

bull DCR Less fluid (5 vs 14 L) less pRBCs (7 u vs 13 u)

less ldquolethal triadrdquo (46 vs 80) survival OR 25

TCCC Order of preference

for fluid resuscitation

bull Fresh whole blood

bull PRBCsFFPPlatelets in 111 ratio

bull PRBCsFFP in 11 ratio

bull PRBCs or FFP

bull Plasmalyte Normosol

bull Lactated Ringers

bull Not recommended Normal Saline

Tranexamic Acid

bull Antithrombolytic

bull ldquoHyperfibrinolysis of traumardquo

bull 1g over 10 min

bull Giving it faster can cause hypotension

bull May give up to 5g (studied up to 250mgkg)

bull Re-dose if hemorrhage is ongoing

Tranexamic Acid

bull CRASH-2 bull Given across a wide spectrum of trauma patients in 40 countries

bull ARR 15

bull Poorly controlled only half went to OR

bull MATTERs bull 17 vs 239 mortality

bull Benefit greatest in those getting MTP

bull MATTERs II bull TXA vs Cryo vs TXA+Cryo

bull 116 vs 236 mortality

bull Best benefit lt1h after injury

bull Some benefit lt3h after injury

bull Possible harm gt3h after injury

Tranexamic Acid

bull CRASH-2 TBI

bull Basically a wash

bull Cole Davenport Brohi TXA did not affect mortality in

overall or non-shock cohorts

bull MVA showed OR of MOF 027 and death 016

bull Valle Allen Higher mortality with TXA if needing gt2L

PRBCs

bull Given 97 min after ADMISSION and after transfusion

Factor VIIa

bull No studies showing mortality benefit

bull Studies showing decreased blood loss

bull $45000dose

bull May consider if still bleeding after TXA

Metabolic acidosis

bull Keep pH above 72

bull Administer THAM (Tromethamine solution) or sodium

bicarbonate to maintain pH

bull Weight in kg x base deficit x 11 = volume of THAM

solution to give (18g500mL)

bull Weight in kg x base deficit x 02 = volume of sodium

bicarb solution to give

Calcium

bull Calcium used up in clots

bull Calcium gobbled up by citrate in stored blood

bull Maintain ionized iCa gt 10 (run on ABG machine)

bull 1g Ca Gluconate for every 4 u FFP

Storage lesions

bull Stored blood is acidic

bull Calcium is chelated by preservatives

bull Platelets decline in function

Thromboelastography

(TEG)

bull Gives a better picture of coagulation status

bull Measures time to initiate clot

bull Speed of formation

bull Strength of clot

bull Fibrinolysis

bull Can help guide transfusion therapy

bull Better outcomes at gt10u PRBCs

bull Fewer units of blood

TEG

TEG Value Transfuse

TEG-ACT gt 140 FFP

R time gt 10 FFP

K time gt 3 Cryo

A angle Cry +- Platelets

MA lt 50 Platelets

LY30 gt3 TXA

REBOA

bull Resuscitative Endovascular Balloon Occlusion of the

Aorta

ER REBOA

Bottom Line

bull Keep them WARM

bull Little to no crystalloid

bull Hypotension is bad for brain injuries

bull Think about MT early

bull 111 ratio

bull Give TXA early

bull Calcium

bull Fix acidosis

bull Balogh Z McKinley BA Cocanour CS Kozar RA Valdivia A Sailors RM Moore FA Supra-normal trauma resuscitation causes more cases of abdominal compartment syndrome Arch Surg 138637-643 2003

bull Duchesne JC Heaney J Guidry C McSwain N Jr Meade P Cohen M Schreiber M Inaba K Skiada D Demetriades D Holcomb J Wade C Cotton B Diluting the benefits of hemostatic resuscitation A multi-institutional analysis J Trauma Acute Care Surg 2013 Jul75(1)76-82 doi 101097TA0b013e3182987df3

bull Guidry C Gleeson E Simms ER Stuke L Meade P McSwain NE Jr Duchesne JC Initial assessment on the impact of crystalloids versus colloids during damage control resuscitation J Surg Res 2013 Jun 15 pii S0022-4804(13)00568-4 doi 101016jjss201305086 [Epub ahead of print]

bull Perel P Roberts I Ker K Colloids versus crystalloids for fluid resuscitation in critically ill patients Cochrane Database Syst Rev 2013 Feb 282CD000567 doi 10100214651858CD000567pub6

bull Zarychanski R Abou-Setta AM Turgeon AF et al Association of Hydroxyethyl Starch Administration With Mortality and Acute Kidney Injury in Critically Ill Patients Requiring Volume Resuscitation A Systematic Review and Meta-analysis JAMA 2013309(7)678-688 doi101001jama2013430

bull Bulger EM May S Kerby JD Emerson S Stiell IG Schreiber MA Brasel KJ Tisherman SA Coimbra R Rizoli S Minei JP Hata JS Sopko G Evans DC Hoyt DB ROC investigators Out-of-hospital hypertonic resuscitation after traumatic hypovolemic shock a randomized placebo controlled trial Ann Surg 2011 Mar253(3)431-41 doi 101097SLA0b013e3181fcdb22

bull Vassar MJ Fischer RP OBrien PE Bachulis BL Chambers JA Hoyt DB Holcroft JW A multicenter trial for resuscitation of injured patients with 75 sodium chloride The effect of added dextran 70 The Multicenter Group for the Study of Hypertonic Saline in Trauma Patients Arch Surg 1993 Sep128(9)1003-11 discussion 1011-3

bull Cooper DJ Myles PS McDermott FT Murray LJ Laidlaw J Cooper G Tremayne AB Bernard SS Ponsford J HTS Study Investigators Prehospital hypertonic saline resuscitation of patients with hypotension and severe traumatic brain injury a randomized controlled trial JAMA 2004 Mar 17291(11)1350-7

bull Duke MD Guidry C Guice J Stuke L Marr AB Hunt JP Meade P McSwain NE Jr Duchesne JC Restrictive fluid resuscitation in combination with damage control resuscitation time for adaptation J Trauma Acute Care Surg 2012 Sep73(3)674-8 doi 101097TA0b013e318265ce1f

bull Pidcoke HF Aden JK Mora AG Borgman MA Spinella PC Dubick MA Blackbourne LH Cap AP Ten-year analysis of transfusion in Operation Iraqi Freedom and Operation Enduring Freedom increased plasma and platelet use correlates with improved survival J Trauma Acute Care Surg 2012 Dec73(6 Suppl 5)S445-52 doi 101097TA0b013e3182754796

bull Morrison CA Carrick MM Norman MA Scott BG Welsh FJ Tsai P Liscum KR Wall MJ Jr Mattox KL Hypotensive resuscitation strategy reduces transfusion requirements and severe postoperative coagulopathy in trauma patients with hemorrhagic shock preliminary results of a randomized controlled trial J Trauma 2011 Mar70(3)652-63 doi 101097TA0b013e31820e77ea

bull Ley EJ Clond MA Srour MK Barnajian M Mirocha J Margulies DR Salim A Emergency department crystalloid resuscitation of 15 L or more is associated with increased mortality in elderly and nonelderly trauma patients J Trauma 2011 Feb70(2)398-400 doi 101097TA0b013e318208f99b

bull Kasotakis G Sideris A Yang Y de Moya M Alam H King DR Tompkins R Velmahos G Inflammation and Host Response to Injury Investigators Aggressive early crystalloid resuscitation adversely affects outcomes in adult blunt trauma patients an analysis of the Glue Grant database J Trauma Acute Care Surg 2013 May74(5)1215-21 discussion 1221-2 doi 101097TA0b013e3182826e13

bull Neal MD Hoffman MK Cuschieri J Minei JP Maier RV Harbrecht BG Billiar TR Peitzman AB Moore EE Cohen MJ Sperry JL Crystalloid to packed red blood cell transfusion ratio in the massively transfused patient when a little goes a long way J Trauma Acute Care Surg 2012 Apr72(4)892-8 doi 101097TA0b013e31823d84a7

bull Niles SE McLaughlin DF Perkins JG et al Increased mortality associated with the early coagulopathy of trauma in combat casualties J Trauma 2008641459-63

bull Brohi K Singh J Heron M Coats T Acute traumatic coagulopathy J Trauma 2003541127-30

bull Cotton BA Gunter OL Isbell J et al Damage control hematology the impact of a trauma exsanguination protocol on survival and blood product utilization J Trauma 2008641177-82

bull Keneally RJ1 Parsons AM1 Willett PB1 Warm fresh whole blood and thoracic traumain iraq and afghanistan J Emerg Trauma Shock 2015 Jan-Mar8(1)21-5

bull Spinella PC1 Perkins JG Grathwohl KW Beekley AC Holcomb JB Warm fresh whole blood is independently associated with improved survival for patients with combat-related traumatic injuries J Trauma 2009 Apr66(4 Suppl)S69-76

bull Wafaisade A1 Lefering R2 Bouillon B3 Boumlhmer AB4 Gaumlszligler M5 Ruppert M5 TraumaRegister DGU Prehospital administration of tranexamic acid in trauma patients Crit Care 2016 May 1220(1)143

bull Ausset S1 Glassberg E Nadler R Sunde G Cap AP Hoffmann C Plang S Sailliol A Tranexamic acid as part of remote damage-control resuscitation in the prehospital setting A critical appraisal of the medical literature and available alternatives J Trauma Acute Care Surg 2015 Jun78(6 Suppl 1)S70-5

bull CRASH-2 trial collaborators Shakur H Roberts I Bautista R Caballero J Coats T Dewan Y El-Sayed H Gogichaishvili T Gupta S Herrera J Hunt B Iribhogbe P Izurieta M Khamis H Komolafe E Marrero MA Mejiacutea-Mantilla J Miranda J Morales C Olaomi O Olldashi F Perel P Peto R Ramana PV Ravi RR Yutthakasemsunt S Effects of tranexamic acid on death vascular occlusive events and blood transfusion in trauma patients with significant haemorrhage (CRASH-2) a randomised placebo-controlled trial Lancet 2010 Jul 3376(9734)23-32

bull Morrison JJ1 Dubose JJ Rasmussen TE Midwinter MJ Military Application of Tranexamic Acid in Trauma Emergency Resuscitation (MATTERs) Study Arch Surg 2012 Feb147(2)113-9

bull Morrison JJ1 Ross JD Dubose JJ Jansen JO Midwinter MJ Rasmussen TE Association of cryoprecipitate and tranexamic acid with improved survival following wartime injury findings from the MATTERs II Study JAMA Surg 2013 Mar148(3)218-25

Blood Ratios

bull The old LOTS of pRBCs = oxygen carrying capacity

bull The now 111 ratio

bull Replace coagulation factorsplatelets

Blood

bull O- for females at or below CBA

bull O+ for everyone else

bull FFP AB is universal donor

bull A is the next safest

Who Needs Massive

Transfusion

bull Systolic BP lt110

bull HRgt 105

bull Hct lt 32

bull pH lt 725

bull 3 of the 4 70 likelihood

bull 44 85 likelihood

bull INR gt 14 (5x mortality)

bull StO2 lt 75

Who Needs Massive

Transfusion

bull Uncontrolled truncal axillary neck or groin bleeding

bull Uncontrolled bleeding secondary to massive soft tissue

injuries

bull Proximal amputation or mangled extremity

bull Clinical signs of coagulopathy

bull Severe hypothermia with blood loss

Which should we give

first

bull We have decent oxygen carrying capacity when anemic

bull Plasma first transfusion may be better

bull Fix the coagulopathy hypothermia acidosis

bull Prehospital freeze dried plasma (FDP)

bull Being studied by US military

bull Used by our European colleagues

bull not FDA approved in the US currently

Fibrinogen

bull Fresh whole blood 1000 mg of fibrinogen

bull FFP 400 mg

bull Platelets 80 mg

bull Cryoprecipitate 2500 mg

bull Transfusion with high ratios of fibrinogen to RBCs have

shown survival benefit

Fresh Whole Blood

Blood

bull Fresh whole blood AT LEAST equivalent to components

bull May improve survival

bull Restricted fluid resuscitation (lt1500 mL crystalloid) OR

of death 069

bull DCR Less fluid (5 vs 14 L) less pRBCs (7 u vs 13 u)

less ldquolethal triadrdquo (46 vs 80) survival OR 25

TCCC Order of preference

for fluid resuscitation

bull Fresh whole blood

bull PRBCsFFPPlatelets in 111 ratio

bull PRBCsFFP in 11 ratio

bull PRBCs or FFP

bull Plasmalyte Normosol

bull Lactated Ringers

bull Not recommended Normal Saline

Tranexamic Acid

bull Antithrombolytic

bull ldquoHyperfibrinolysis of traumardquo

bull 1g over 10 min

bull Giving it faster can cause hypotension

bull May give up to 5g (studied up to 250mgkg)

bull Re-dose if hemorrhage is ongoing

Tranexamic Acid

bull CRASH-2 bull Given across a wide spectrum of trauma patients in 40 countries

bull ARR 15

bull Poorly controlled only half went to OR

bull MATTERs bull 17 vs 239 mortality

bull Benefit greatest in those getting MTP

bull MATTERs II bull TXA vs Cryo vs TXA+Cryo

bull 116 vs 236 mortality

bull Best benefit lt1h after injury

bull Some benefit lt3h after injury

bull Possible harm gt3h after injury

Tranexamic Acid

bull CRASH-2 TBI

bull Basically a wash

bull Cole Davenport Brohi TXA did not affect mortality in

overall or non-shock cohorts

bull MVA showed OR of MOF 027 and death 016

bull Valle Allen Higher mortality with TXA if needing gt2L

PRBCs

bull Given 97 min after ADMISSION and after transfusion

Factor VIIa

bull No studies showing mortality benefit

bull Studies showing decreased blood loss

bull $45000dose

bull May consider if still bleeding after TXA

Metabolic acidosis

bull Keep pH above 72

bull Administer THAM (Tromethamine solution) or sodium

bicarbonate to maintain pH

bull Weight in kg x base deficit x 11 = volume of THAM

solution to give (18g500mL)

bull Weight in kg x base deficit x 02 = volume of sodium

bicarb solution to give

Calcium

bull Calcium used up in clots

bull Calcium gobbled up by citrate in stored blood

bull Maintain ionized iCa gt 10 (run on ABG machine)

bull 1g Ca Gluconate for every 4 u FFP

Storage lesions

bull Stored blood is acidic

bull Calcium is chelated by preservatives

bull Platelets decline in function

Thromboelastography

(TEG)

bull Gives a better picture of coagulation status

bull Measures time to initiate clot

bull Speed of formation

bull Strength of clot

bull Fibrinolysis

bull Can help guide transfusion therapy

bull Better outcomes at gt10u PRBCs

bull Fewer units of blood

TEG

TEG Value Transfuse

TEG-ACT gt 140 FFP

R time gt 10 FFP

K time gt 3 Cryo

A angle Cry +- Platelets

MA lt 50 Platelets

LY30 gt3 TXA

REBOA

bull Resuscitative Endovascular Balloon Occlusion of the

Aorta

ER REBOA

Bottom Line

bull Keep them WARM

bull Little to no crystalloid

bull Hypotension is bad for brain injuries

bull Think about MT early

bull 111 ratio

bull Give TXA early

bull Calcium

bull Fix acidosis

bull Balogh Z McKinley BA Cocanour CS Kozar RA Valdivia A Sailors RM Moore FA Supra-normal trauma resuscitation causes more cases of abdominal compartment syndrome Arch Surg 138637-643 2003

bull Duchesne JC Heaney J Guidry C McSwain N Jr Meade P Cohen M Schreiber M Inaba K Skiada D Demetriades D Holcomb J Wade C Cotton B Diluting the benefits of hemostatic resuscitation A multi-institutional analysis J Trauma Acute Care Surg 2013 Jul75(1)76-82 doi 101097TA0b013e3182987df3

bull Guidry C Gleeson E Simms ER Stuke L Meade P McSwain NE Jr Duchesne JC Initial assessment on the impact of crystalloids versus colloids during damage control resuscitation J Surg Res 2013 Jun 15 pii S0022-4804(13)00568-4 doi 101016jjss201305086 [Epub ahead of print]

bull Perel P Roberts I Ker K Colloids versus crystalloids for fluid resuscitation in critically ill patients Cochrane Database Syst Rev 2013 Feb 282CD000567 doi 10100214651858CD000567pub6

bull Zarychanski R Abou-Setta AM Turgeon AF et al Association of Hydroxyethyl Starch Administration With Mortality and Acute Kidney Injury in Critically Ill Patients Requiring Volume Resuscitation A Systematic Review and Meta-analysis JAMA 2013309(7)678-688 doi101001jama2013430

bull Bulger EM May S Kerby JD Emerson S Stiell IG Schreiber MA Brasel KJ Tisherman SA Coimbra R Rizoli S Minei JP Hata JS Sopko G Evans DC Hoyt DB ROC investigators Out-of-hospital hypertonic resuscitation after traumatic hypovolemic shock a randomized placebo controlled trial Ann Surg 2011 Mar253(3)431-41 doi 101097SLA0b013e3181fcdb22

bull Vassar MJ Fischer RP OBrien PE Bachulis BL Chambers JA Hoyt DB Holcroft JW A multicenter trial for resuscitation of injured patients with 75 sodium chloride The effect of added dextran 70 The Multicenter Group for the Study of Hypertonic Saline in Trauma Patients Arch Surg 1993 Sep128(9)1003-11 discussion 1011-3

bull Cooper DJ Myles PS McDermott FT Murray LJ Laidlaw J Cooper G Tremayne AB Bernard SS Ponsford J HTS Study Investigators Prehospital hypertonic saline resuscitation of patients with hypotension and severe traumatic brain injury a randomized controlled trial JAMA 2004 Mar 17291(11)1350-7

bull Duke MD Guidry C Guice J Stuke L Marr AB Hunt JP Meade P McSwain NE Jr Duchesne JC Restrictive fluid resuscitation in combination with damage control resuscitation time for adaptation J Trauma Acute Care Surg 2012 Sep73(3)674-8 doi 101097TA0b013e318265ce1f

bull Pidcoke HF Aden JK Mora AG Borgman MA Spinella PC Dubick MA Blackbourne LH Cap AP Ten-year analysis of transfusion in Operation Iraqi Freedom and Operation Enduring Freedom increased plasma and platelet use correlates with improved survival J Trauma Acute Care Surg 2012 Dec73(6 Suppl 5)S445-52 doi 101097TA0b013e3182754796

bull Morrison CA Carrick MM Norman MA Scott BG Welsh FJ Tsai P Liscum KR Wall MJ Jr Mattox KL Hypotensive resuscitation strategy reduces transfusion requirements and severe postoperative coagulopathy in trauma patients with hemorrhagic shock preliminary results of a randomized controlled trial J Trauma 2011 Mar70(3)652-63 doi 101097TA0b013e31820e77ea

bull Ley EJ Clond MA Srour MK Barnajian M Mirocha J Margulies DR Salim A Emergency department crystalloid resuscitation of 15 L or more is associated with increased mortality in elderly and nonelderly trauma patients J Trauma 2011 Feb70(2)398-400 doi 101097TA0b013e318208f99b

bull Kasotakis G Sideris A Yang Y de Moya M Alam H King DR Tompkins R Velmahos G Inflammation and Host Response to Injury Investigators Aggressive early crystalloid resuscitation adversely affects outcomes in adult blunt trauma patients an analysis of the Glue Grant database J Trauma Acute Care Surg 2013 May74(5)1215-21 discussion 1221-2 doi 101097TA0b013e3182826e13

bull Neal MD Hoffman MK Cuschieri J Minei JP Maier RV Harbrecht BG Billiar TR Peitzman AB Moore EE Cohen MJ Sperry JL Crystalloid to packed red blood cell transfusion ratio in the massively transfused patient when a little goes a long way J Trauma Acute Care Surg 2012 Apr72(4)892-8 doi 101097TA0b013e31823d84a7

bull Niles SE McLaughlin DF Perkins JG et al Increased mortality associated with the early coagulopathy of trauma in combat casualties J Trauma 2008641459-63

bull Brohi K Singh J Heron M Coats T Acute traumatic coagulopathy J Trauma 2003541127-30

bull Cotton BA Gunter OL Isbell J et al Damage control hematology the impact of a trauma exsanguination protocol on survival and blood product utilization J Trauma 2008641177-82

bull Keneally RJ1 Parsons AM1 Willett PB1 Warm fresh whole blood and thoracic traumain iraq and afghanistan J Emerg Trauma Shock 2015 Jan-Mar8(1)21-5

bull Spinella PC1 Perkins JG Grathwohl KW Beekley AC Holcomb JB Warm fresh whole blood is independently associated with improved survival for patients with combat-related traumatic injuries J Trauma 2009 Apr66(4 Suppl)S69-76

bull Wafaisade A1 Lefering R2 Bouillon B3 Boumlhmer AB4 Gaumlszligler M5 Ruppert M5 TraumaRegister DGU Prehospital administration of tranexamic acid in trauma patients Crit Care 2016 May 1220(1)143

bull Ausset S1 Glassberg E Nadler R Sunde G Cap AP Hoffmann C Plang S Sailliol A Tranexamic acid as part of remote damage-control resuscitation in the prehospital setting A critical appraisal of the medical literature and available alternatives J Trauma Acute Care Surg 2015 Jun78(6 Suppl 1)S70-5

bull CRASH-2 trial collaborators Shakur H Roberts I Bautista R Caballero J Coats T Dewan Y El-Sayed H Gogichaishvili T Gupta S Herrera J Hunt B Iribhogbe P Izurieta M Khamis H Komolafe E Marrero MA Mejiacutea-Mantilla J Miranda J Morales C Olaomi O Olldashi F Perel P Peto R Ramana PV Ravi RR Yutthakasemsunt S Effects of tranexamic acid on death vascular occlusive events and blood transfusion in trauma patients with significant haemorrhage (CRASH-2) a randomised placebo-controlled trial Lancet 2010 Jul 3376(9734)23-32

bull Morrison JJ1 Dubose JJ Rasmussen TE Midwinter MJ Military Application of Tranexamic Acid in Trauma Emergency Resuscitation (MATTERs) Study Arch Surg 2012 Feb147(2)113-9

bull Morrison JJ1 Ross JD Dubose JJ Jansen JO Midwinter MJ Rasmussen TE Association of cryoprecipitate and tranexamic acid with improved survival following wartime injury findings from the MATTERs II Study JAMA Surg 2013 Mar148(3)218-25

Blood

bull O- for females at or below CBA

bull O+ for everyone else

bull FFP AB is universal donor

bull A is the next safest

Who Needs Massive

Transfusion

bull Systolic BP lt110

bull HRgt 105

bull Hct lt 32

bull pH lt 725

bull 3 of the 4 70 likelihood

bull 44 85 likelihood

bull INR gt 14 (5x mortality)

bull StO2 lt 75

Who Needs Massive

Transfusion

bull Uncontrolled truncal axillary neck or groin bleeding

bull Uncontrolled bleeding secondary to massive soft tissue

injuries

bull Proximal amputation or mangled extremity

bull Clinical signs of coagulopathy

bull Severe hypothermia with blood loss

Which should we give

first

bull We have decent oxygen carrying capacity when anemic

bull Plasma first transfusion may be better

bull Fix the coagulopathy hypothermia acidosis

bull Prehospital freeze dried plasma (FDP)

bull Being studied by US military

bull Used by our European colleagues

bull not FDA approved in the US currently

Fibrinogen

bull Fresh whole blood 1000 mg of fibrinogen

bull FFP 400 mg

bull Platelets 80 mg

bull Cryoprecipitate 2500 mg

bull Transfusion with high ratios of fibrinogen to RBCs have

shown survival benefit

Fresh Whole Blood

Blood

bull Fresh whole blood AT LEAST equivalent to components

bull May improve survival

bull Restricted fluid resuscitation (lt1500 mL crystalloid) OR

of death 069

bull DCR Less fluid (5 vs 14 L) less pRBCs (7 u vs 13 u)

less ldquolethal triadrdquo (46 vs 80) survival OR 25

TCCC Order of preference

for fluid resuscitation

bull Fresh whole blood

bull PRBCsFFPPlatelets in 111 ratio

bull PRBCsFFP in 11 ratio

bull PRBCs or FFP

bull Plasmalyte Normosol

bull Lactated Ringers

bull Not recommended Normal Saline

Tranexamic Acid

bull Antithrombolytic

bull ldquoHyperfibrinolysis of traumardquo

bull 1g over 10 min

bull Giving it faster can cause hypotension

bull May give up to 5g (studied up to 250mgkg)

bull Re-dose if hemorrhage is ongoing

Tranexamic Acid

bull CRASH-2 bull Given across a wide spectrum of trauma patients in 40 countries

bull ARR 15

bull Poorly controlled only half went to OR

bull MATTERs bull 17 vs 239 mortality

bull Benefit greatest in those getting MTP

bull MATTERs II bull TXA vs Cryo vs TXA+Cryo

bull 116 vs 236 mortality

bull Best benefit lt1h after injury

bull Some benefit lt3h after injury

bull Possible harm gt3h after injury

Tranexamic Acid

bull CRASH-2 TBI

bull Basically a wash

bull Cole Davenport Brohi TXA did not affect mortality in

overall or non-shock cohorts

bull MVA showed OR of MOF 027 and death 016

bull Valle Allen Higher mortality with TXA if needing gt2L

PRBCs

bull Given 97 min after ADMISSION and after transfusion

Factor VIIa

bull No studies showing mortality benefit

bull Studies showing decreased blood loss

bull $45000dose

bull May consider if still bleeding after TXA

Metabolic acidosis

bull Keep pH above 72

bull Administer THAM (Tromethamine solution) or sodium

bicarbonate to maintain pH

bull Weight in kg x base deficit x 11 = volume of THAM

solution to give (18g500mL)

bull Weight in kg x base deficit x 02 = volume of sodium

bicarb solution to give

Calcium

bull Calcium used up in clots

bull Calcium gobbled up by citrate in stored blood

bull Maintain ionized iCa gt 10 (run on ABG machine)

bull 1g Ca Gluconate for every 4 u FFP

Storage lesions

bull Stored blood is acidic

bull Calcium is chelated by preservatives

bull Platelets decline in function

Thromboelastography

(TEG)

bull Gives a better picture of coagulation status

bull Measures time to initiate clot

bull Speed of formation

bull Strength of clot

bull Fibrinolysis

bull Can help guide transfusion therapy

bull Better outcomes at gt10u PRBCs

bull Fewer units of blood

TEG

TEG Value Transfuse

TEG-ACT gt 140 FFP

R time gt 10 FFP

K time gt 3 Cryo

A angle Cry +- Platelets

MA lt 50 Platelets

LY30 gt3 TXA

REBOA

bull Resuscitative Endovascular Balloon Occlusion of the

Aorta

ER REBOA

Bottom Line

bull Keep them WARM

bull Little to no crystalloid

bull Hypotension is bad for brain injuries

bull Think about MT early

bull 111 ratio

bull Give TXA early

bull Calcium

bull Fix acidosis

bull Balogh Z McKinley BA Cocanour CS Kozar RA Valdivia A Sailors RM Moore FA Supra-normal trauma resuscitation causes more cases of abdominal compartment syndrome Arch Surg 138637-643 2003

bull Duchesne JC Heaney J Guidry C McSwain N Jr Meade P Cohen M Schreiber M Inaba K Skiada D Demetriades D Holcomb J Wade C Cotton B Diluting the benefits of hemostatic resuscitation A multi-institutional analysis J Trauma Acute Care Surg 2013 Jul75(1)76-82 doi 101097TA0b013e3182987df3

bull Guidry C Gleeson E Simms ER Stuke L Meade P McSwain NE Jr Duchesne JC Initial assessment on the impact of crystalloids versus colloids during damage control resuscitation J Surg Res 2013 Jun 15 pii S0022-4804(13)00568-4 doi 101016jjss201305086 [Epub ahead of print]

bull Perel P Roberts I Ker K Colloids versus crystalloids for fluid resuscitation in critically ill patients Cochrane Database Syst Rev 2013 Feb 282CD000567 doi 10100214651858CD000567pub6

bull Zarychanski R Abou-Setta AM Turgeon AF et al Association of Hydroxyethyl Starch Administration With Mortality and Acute Kidney Injury in Critically Ill Patients Requiring Volume Resuscitation A Systematic Review and Meta-analysis JAMA 2013309(7)678-688 doi101001jama2013430

bull Bulger EM May S Kerby JD Emerson S Stiell IG Schreiber MA Brasel KJ Tisherman SA Coimbra R Rizoli S Minei JP Hata JS Sopko G Evans DC Hoyt DB ROC investigators Out-of-hospital hypertonic resuscitation after traumatic hypovolemic shock a randomized placebo controlled trial Ann Surg 2011 Mar253(3)431-41 doi 101097SLA0b013e3181fcdb22

bull Vassar MJ Fischer RP OBrien PE Bachulis BL Chambers JA Hoyt DB Holcroft JW A multicenter trial for resuscitation of injured patients with 75 sodium chloride The effect of added dextran 70 The Multicenter Group for the Study of Hypertonic Saline in Trauma Patients Arch Surg 1993 Sep128(9)1003-11 discussion 1011-3

bull Cooper DJ Myles PS McDermott FT Murray LJ Laidlaw J Cooper G Tremayne AB Bernard SS Ponsford J HTS Study Investigators Prehospital hypertonic saline resuscitation of patients with hypotension and severe traumatic brain injury a randomized controlled trial JAMA 2004 Mar 17291(11)1350-7

bull Duke MD Guidry C Guice J Stuke L Marr AB Hunt JP Meade P McSwain NE Jr Duchesne JC Restrictive fluid resuscitation in combination with damage control resuscitation time for adaptation J Trauma Acute Care Surg 2012 Sep73(3)674-8 doi 101097TA0b013e318265ce1f

bull Pidcoke HF Aden JK Mora AG Borgman MA Spinella PC Dubick MA Blackbourne LH Cap AP Ten-year analysis of transfusion in Operation Iraqi Freedom and Operation Enduring Freedom increased plasma and platelet use correlates with improved survival J Trauma Acute Care Surg 2012 Dec73(6 Suppl 5)S445-52 doi 101097TA0b013e3182754796

bull Morrison CA Carrick MM Norman MA Scott BG Welsh FJ Tsai P Liscum KR Wall MJ Jr Mattox KL Hypotensive resuscitation strategy reduces transfusion requirements and severe postoperative coagulopathy in trauma patients with hemorrhagic shock preliminary results of a randomized controlled trial J Trauma 2011 Mar70(3)652-63 doi 101097TA0b013e31820e77ea

bull Ley EJ Clond MA Srour MK Barnajian M Mirocha J Margulies DR Salim A Emergency department crystalloid resuscitation of 15 L or more is associated with increased mortality in elderly and nonelderly trauma patients J Trauma 2011 Feb70(2)398-400 doi 101097TA0b013e318208f99b

bull Kasotakis G Sideris A Yang Y de Moya M Alam H King DR Tompkins R Velmahos G Inflammation and Host Response to Injury Investigators Aggressive early crystalloid resuscitation adversely affects outcomes in adult blunt trauma patients an analysis of the Glue Grant database J Trauma Acute Care Surg 2013 May74(5)1215-21 discussion 1221-2 doi 101097TA0b013e3182826e13

bull Neal MD Hoffman MK Cuschieri J Minei JP Maier RV Harbrecht BG Billiar TR Peitzman AB Moore EE Cohen MJ Sperry JL Crystalloid to packed red blood cell transfusion ratio in the massively transfused patient when a little goes a long way J Trauma Acute Care Surg 2012 Apr72(4)892-8 doi 101097TA0b013e31823d84a7

bull Niles SE McLaughlin DF Perkins JG et al Increased mortality associated with the early coagulopathy of trauma in combat casualties J Trauma 2008641459-63

bull Brohi K Singh J Heron M Coats T Acute traumatic coagulopathy J Trauma 2003541127-30

bull Cotton BA Gunter OL Isbell J et al Damage control hematology the impact of a trauma exsanguination protocol on survival and blood product utilization J Trauma 2008641177-82

bull Keneally RJ1 Parsons AM1 Willett PB1 Warm fresh whole blood and thoracic traumain iraq and afghanistan J Emerg Trauma Shock 2015 Jan-Mar8(1)21-5

bull Spinella PC1 Perkins JG Grathwohl KW Beekley AC Holcomb JB Warm fresh whole blood is independently associated with improved survival for patients with combat-related traumatic injuries J Trauma 2009 Apr66(4 Suppl)S69-76

bull Wafaisade A1 Lefering R2 Bouillon B3 Boumlhmer AB4 Gaumlszligler M5 Ruppert M5 TraumaRegister DGU Prehospital administration of tranexamic acid in trauma patients Crit Care 2016 May 1220(1)143

bull Ausset S1 Glassberg E Nadler R Sunde G Cap AP Hoffmann C Plang S Sailliol A Tranexamic acid as part of remote damage-control resuscitation in the prehospital setting A critical appraisal of the medical literature and available alternatives J Trauma Acute Care Surg 2015 Jun78(6 Suppl 1)S70-5

bull CRASH-2 trial collaborators Shakur H Roberts I Bautista R Caballero J Coats T Dewan Y El-Sayed H Gogichaishvili T Gupta S Herrera J Hunt B Iribhogbe P Izurieta M Khamis H Komolafe E Marrero MA Mejiacutea-Mantilla J Miranda J Morales C Olaomi O Olldashi F Perel P Peto R Ramana PV Ravi RR Yutthakasemsunt S Effects of tranexamic acid on death vascular occlusive events and blood transfusion in trauma patients with significant haemorrhage (CRASH-2) a randomised placebo-controlled trial Lancet 2010 Jul 3376(9734)23-32

bull Morrison JJ1 Dubose JJ Rasmussen TE Midwinter MJ Military Application of Tranexamic Acid in Trauma Emergency Resuscitation (MATTERs) Study Arch Surg 2012 Feb147(2)113-9

bull Morrison JJ1 Ross JD Dubose JJ Jansen JO Midwinter MJ Rasmussen TE Association of cryoprecipitate and tranexamic acid with improved survival following wartime injury findings from the MATTERs II Study JAMA Surg 2013 Mar148(3)218-25

Who Needs Massive

Transfusion

bull Systolic BP lt110

bull HRgt 105

bull Hct lt 32

bull pH lt 725

bull 3 of the 4 70 likelihood

bull 44 85 likelihood

bull INR gt 14 (5x mortality)

bull StO2 lt 75

Who Needs Massive

Transfusion

bull Uncontrolled truncal axillary neck or groin bleeding

bull Uncontrolled bleeding secondary to massive soft tissue

injuries

bull Proximal amputation or mangled extremity

bull Clinical signs of coagulopathy

bull Severe hypothermia with blood loss

Which should we give

first

bull We have decent oxygen carrying capacity when anemic

bull Plasma first transfusion may be better

bull Fix the coagulopathy hypothermia acidosis

bull Prehospital freeze dried plasma (FDP)

bull Being studied by US military

bull Used by our European colleagues

bull not FDA approved in the US currently

Fibrinogen

bull Fresh whole blood 1000 mg of fibrinogen

bull FFP 400 mg

bull Platelets 80 mg

bull Cryoprecipitate 2500 mg

bull Transfusion with high ratios of fibrinogen to RBCs have

shown survival benefit

Fresh Whole Blood

Blood

bull Fresh whole blood AT LEAST equivalent to components

bull May improve survival

bull Restricted fluid resuscitation (lt1500 mL crystalloid) OR

of death 069

bull DCR Less fluid (5 vs 14 L) less pRBCs (7 u vs 13 u)

less ldquolethal triadrdquo (46 vs 80) survival OR 25

TCCC Order of preference

for fluid resuscitation

bull Fresh whole blood

bull PRBCsFFPPlatelets in 111 ratio

bull PRBCsFFP in 11 ratio

bull PRBCs or FFP

bull Plasmalyte Normosol

bull Lactated Ringers

bull Not recommended Normal Saline

Tranexamic Acid

bull Antithrombolytic

bull ldquoHyperfibrinolysis of traumardquo

bull 1g over 10 min

bull Giving it faster can cause hypotension

bull May give up to 5g (studied up to 250mgkg)

bull Re-dose if hemorrhage is ongoing

Tranexamic Acid

bull CRASH-2 bull Given across a wide spectrum of trauma patients in 40 countries

bull ARR 15

bull Poorly controlled only half went to OR

bull MATTERs bull 17 vs 239 mortality

bull Benefit greatest in those getting MTP

bull MATTERs II bull TXA vs Cryo vs TXA+Cryo

bull 116 vs 236 mortality

bull Best benefit lt1h after injury

bull Some benefit lt3h after injury

bull Possible harm gt3h after injury

Tranexamic Acid

bull CRASH-2 TBI

bull Basically a wash

bull Cole Davenport Brohi TXA did not affect mortality in

overall or non-shock cohorts

bull MVA showed OR of MOF 027 and death 016

bull Valle Allen Higher mortality with TXA if needing gt2L

PRBCs

bull Given 97 min after ADMISSION and after transfusion

Factor VIIa

bull No studies showing mortality benefit

bull Studies showing decreased blood loss

bull $45000dose

bull May consider if still bleeding after TXA

Metabolic acidosis

bull Keep pH above 72

bull Administer THAM (Tromethamine solution) or sodium

bicarbonate to maintain pH

bull Weight in kg x base deficit x 11 = volume of THAM

solution to give (18g500mL)

bull Weight in kg x base deficit x 02 = volume of sodium

bicarb solution to give

Calcium

bull Calcium used up in clots

bull Calcium gobbled up by citrate in stored blood

bull Maintain ionized iCa gt 10 (run on ABG machine)

bull 1g Ca Gluconate for every 4 u FFP

Storage lesions

bull Stored blood is acidic

bull Calcium is chelated by preservatives

bull Platelets decline in function

Thromboelastography

(TEG)

bull Gives a better picture of coagulation status

bull Measures time to initiate clot

bull Speed of formation

bull Strength of clot

bull Fibrinolysis

bull Can help guide transfusion therapy

bull Better outcomes at gt10u PRBCs

bull Fewer units of blood

TEG

TEG Value Transfuse

TEG-ACT gt 140 FFP

R time gt 10 FFP

K time gt 3 Cryo

A angle Cry +- Platelets

MA lt 50 Platelets

LY30 gt3 TXA

REBOA

bull Resuscitative Endovascular Balloon Occlusion of the

Aorta

ER REBOA

Bottom Line

bull Keep them WARM

bull Little to no crystalloid

bull Hypotension is bad for brain injuries

bull Think about MT early

bull 111 ratio

bull Give TXA early

bull Calcium

bull Fix acidosis

bull Balogh Z McKinley BA Cocanour CS Kozar RA Valdivia A Sailors RM Moore FA Supra-normal trauma resuscitation causes more cases of abdominal compartment syndrome Arch Surg 138637-643 2003

bull Duchesne JC Heaney J Guidry C McSwain N Jr Meade P Cohen M Schreiber M Inaba K Skiada D Demetriades D Holcomb J Wade C Cotton B Diluting the benefits of hemostatic resuscitation A multi-institutional analysis J Trauma Acute Care Surg 2013 Jul75(1)76-82 doi 101097TA0b013e3182987df3

bull Guidry C Gleeson E Simms ER Stuke L Meade P McSwain NE Jr Duchesne JC Initial assessment on the impact of crystalloids versus colloids during damage control resuscitation J Surg Res 2013 Jun 15 pii S0022-4804(13)00568-4 doi 101016jjss201305086 [Epub ahead of print]

bull Perel P Roberts I Ker K Colloids versus crystalloids for fluid resuscitation in critically ill patients Cochrane Database Syst Rev 2013 Feb 282CD000567 doi 10100214651858CD000567pub6

bull Zarychanski R Abou-Setta AM Turgeon AF et al Association of Hydroxyethyl Starch Administration With Mortality and Acute Kidney Injury in Critically Ill Patients Requiring Volume Resuscitation A Systematic Review and Meta-analysis JAMA 2013309(7)678-688 doi101001jama2013430

bull Bulger EM May S Kerby JD Emerson S Stiell IG Schreiber MA Brasel KJ Tisherman SA Coimbra R Rizoli S Minei JP Hata JS Sopko G Evans DC Hoyt DB ROC investigators Out-of-hospital hypertonic resuscitation after traumatic hypovolemic shock a randomized placebo controlled trial Ann Surg 2011 Mar253(3)431-41 doi 101097SLA0b013e3181fcdb22

bull Vassar MJ Fischer RP OBrien PE Bachulis BL Chambers JA Hoyt DB Holcroft JW A multicenter trial for resuscitation of injured patients with 75 sodium chloride The effect of added dextran 70 The Multicenter Group for the Study of Hypertonic Saline in Trauma Patients Arch Surg 1993 Sep128(9)1003-11 discussion 1011-3

bull Cooper DJ Myles PS McDermott FT Murray LJ Laidlaw J Cooper G Tremayne AB Bernard SS Ponsford J HTS Study Investigators Prehospital hypertonic saline resuscitation of patients with hypotension and severe traumatic brain injury a randomized controlled trial JAMA 2004 Mar 17291(11)1350-7

bull Duke MD Guidry C Guice J Stuke L Marr AB Hunt JP Meade P McSwain NE Jr Duchesne JC Restrictive fluid resuscitation in combination with damage control resuscitation time for adaptation J Trauma Acute Care Surg 2012 Sep73(3)674-8 doi 101097TA0b013e318265ce1f

bull Pidcoke HF Aden JK Mora AG Borgman MA Spinella PC Dubick MA Blackbourne LH Cap AP Ten-year analysis of transfusion in Operation Iraqi Freedom and Operation Enduring Freedom increased plasma and platelet use correlates with improved survival J Trauma Acute Care Surg 2012 Dec73(6 Suppl 5)S445-52 doi 101097TA0b013e3182754796

bull Morrison CA Carrick MM Norman MA Scott BG Welsh FJ Tsai P Liscum KR Wall MJ Jr Mattox KL Hypotensive resuscitation strategy reduces transfusion requirements and severe postoperative coagulopathy in trauma patients with hemorrhagic shock preliminary results of a randomized controlled trial J Trauma 2011 Mar70(3)652-63 doi 101097TA0b013e31820e77ea

bull Ley EJ Clond MA Srour MK Barnajian M Mirocha J Margulies DR Salim A Emergency department crystalloid resuscitation of 15 L or more is associated with increased mortality in elderly and nonelderly trauma patients J Trauma 2011 Feb70(2)398-400 doi 101097TA0b013e318208f99b

bull Kasotakis G Sideris A Yang Y de Moya M Alam H King DR Tompkins R Velmahos G Inflammation and Host Response to Injury Investigators Aggressive early crystalloid resuscitation adversely affects outcomes in adult blunt trauma patients an analysis of the Glue Grant database J Trauma Acute Care Surg 2013 May74(5)1215-21 discussion 1221-2 doi 101097TA0b013e3182826e13

bull Neal MD Hoffman MK Cuschieri J Minei JP Maier RV Harbrecht BG Billiar TR Peitzman AB Moore EE Cohen MJ Sperry JL Crystalloid to packed red blood cell transfusion ratio in the massively transfused patient when a little goes a long way J Trauma Acute Care Surg 2012 Apr72(4)892-8 doi 101097TA0b013e31823d84a7

bull Niles SE McLaughlin DF Perkins JG et al Increased mortality associated with the early coagulopathy of trauma in combat casualties J Trauma 2008641459-63

bull Brohi K Singh J Heron M Coats T Acute traumatic coagulopathy J Trauma 2003541127-30

bull Cotton BA Gunter OL Isbell J et al Damage control hematology the impact of a trauma exsanguination protocol on survival and blood product utilization J Trauma 2008641177-82

bull Keneally RJ1 Parsons AM1 Willett PB1 Warm fresh whole blood and thoracic traumain iraq and afghanistan J Emerg Trauma Shock 2015 Jan-Mar8(1)21-5

bull Spinella PC1 Perkins JG Grathwohl KW Beekley AC Holcomb JB Warm fresh whole blood is independently associated with improved survival for patients with combat-related traumatic injuries J Trauma 2009 Apr66(4 Suppl)S69-76

bull Wafaisade A1 Lefering R2 Bouillon B3 Boumlhmer AB4 Gaumlszligler M5 Ruppert M5 TraumaRegister DGU Prehospital administration of tranexamic acid in trauma patients Crit Care 2016 May 1220(1)143

bull Ausset S1 Glassberg E Nadler R Sunde G Cap AP Hoffmann C Plang S Sailliol A Tranexamic acid as part of remote damage-control resuscitation in the prehospital setting A critical appraisal of the medical literature and available alternatives J Trauma Acute Care Surg 2015 Jun78(6 Suppl 1)S70-5

bull CRASH-2 trial collaborators Shakur H Roberts I Bautista R Caballero J Coats T Dewan Y El-Sayed H Gogichaishvili T Gupta S Herrera J Hunt B Iribhogbe P Izurieta M Khamis H Komolafe E Marrero MA Mejiacutea-Mantilla J Miranda J Morales C Olaomi O Olldashi F Perel P Peto R Ramana PV Ravi RR Yutthakasemsunt S Effects of tranexamic acid on death vascular occlusive events and blood transfusion in trauma patients with significant haemorrhage (CRASH-2) a randomised placebo-controlled trial Lancet 2010 Jul 3376(9734)23-32

bull Morrison JJ1 Dubose JJ Rasmussen TE Midwinter MJ Military Application of Tranexamic Acid in Trauma Emergency Resuscitation (MATTERs) Study Arch Surg 2012 Feb147(2)113-9

bull Morrison JJ1 Ross JD Dubose JJ Jansen JO Midwinter MJ Rasmussen TE Association of cryoprecipitate and tranexamic acid with improved survival following wartime injury findings from the MATTERs II Study JAMA Surg 2013 Mar148(3)218-25

Who Needs Massive

Transfusion

bull Uncontrolled truncal axillary neck or groin bleeding

bull Uncontrolled bleeding secondary to massive soft tissue

injuries

bull Proximal amputation or mangled extremity

bull Clinical signs of coagulopathy

bull Severe hypothermia with blood loss

Which should we give

first

bull We have decent oxygen carrying capacity when anemic

bull Plasma first transfusion may be better

bull Fix the coagulopathy hypothermia acidosis

bull Prehospital freeze dried plasma (FDP)

bull Being studied by US military

bull Used by our European colleagues

bull not FDA approved in the US currently

Fibrinogen

bull Fresh whole blood 1000 mg of fibrinogen

bull FFP 400 mg

bull Platelets 80 mg

bull Cryoprecipitate 2500 mg

bull Transfusion with high ratios of fibrinogen to RBCs have

shown survival benefit

Fresh Whole Blood

Blood

bull Fresh whole blood AT LEAST equivalent to components

bull May improve survival

bull Restricted fluid resuscitation (lt1500 mL crystalloid) OR

of death 069

bull DCR Less fluid (5 vs 14 L) less pRBCs (7 u vs 13 u)

less ldquolethal triadrdquo (46 vs 80) survival OR 25

TCCC Order of preference

for fluid resuscitation

bull Fresh whole blood

bull PRBCsFFPPlatelets in 111 ratio

bull PRBCsFFP in 11 ratio

bull PRBCs or FFP

bull Plasmalyte Normosol

bull Lactated Ringers

bull Not recommended Normal Saline

Tranexamic Acid

bull Antithrombolytic

bull ldquoHyperfibrinolysis of traumardquo

bull 1g over 10 min

bull Giving it faster can cause hypotension

bull May give up to 5g (studied up to 250mgkg)

bull Re-dose if hemorrhage is ongoing

Tranexamic Acid

bull CRASH-2 bull Given across a wide spectrum of trauma patients in 40 countries

bull ARR 15

bull Poorly controlled only half went to OR

bull MATTERs bull 17 vs 239 mortality

bull Benefit greatest in those getting MTP

bull MATTERs II bull TXA vs Cryo vs TXA+Cryo

bull 116 vs 236 mortality

bull Best benefit lt1h after injury

bull Some benefit lt3h after injury

bull Possible harm gt3h after injury

Tranexamic Acid

bull CRASH-2 TBI

bull Basically a wash

bull Cole Davenport Brohi TXA did not affect mortality in

overall or non-shock cohorts

bull MVA showed OR of MOF 027 and death 016

bull Valle Allen Higher mortality with TXA if needing gt2L

PRBCs

bull Given 97 min after ADMISSION and after transfusion

Factor VIIa

bull No studies showing mortality benefit

bull Studies showing decreased blood loss

bull $45000dose

bull May consider if still bleeding after TXA

Metabolic acidosis

bull Keep pH above 72

bull Administer THAM (Tromethamine solution) or sodium

bicarbonate to maintain pH

bull Weight in kg x base deficit x 11 = volume of THAM

solution to give (18g500mL)

bull Weight in kg x base deficit x 02 = volume of sodium

bicarb solution to give

Calcium

bull Calcium used up in clots

bull Calcium gobbled up by citrate in stored blood

bull Maintain ionized iCa gt 10 (run on ABG machine)

bull 1g Ca Gluconate for every 4 u FFP

Storage lesions

bull Stored blood is acidic

bull Calcium is chelated by preservatives

bull Platelets decline in function

Thromboelastography

(TEG)

bull Gives a better picture of coagulation status

bull Measures time to initiate clot

bull Speed of formation

bull Strength of clot

bull Fibrinolysis

bull Can help guide transfusion therapy

bull Better outcomes at gt10u PRBCs

bull Fewer units of blood

TEG

TEG Value Transfuse

TEG-ACT gt 140 FFP

R time gt 10 FFP

K time gt 3 Cryo

A angle Cry +- Platelets

MA lt 50 Platelets

LY30 gt3 TXA

REBOA

bull Resuscitative Endovascular Balloon Occlusion of the

Aorta

ER REBOA

Bottom Line

bull Keep them WARM

bull Little to no crystalloid

bull Hypotension is bad for brain injuries

bull Think about MT early

bull 111 ratio

bull Give TXA early

bull Calcium

bull Fix acidosis

bull Balogh Z McKinley BA Cocanour CS Kozar RA Valdivia A Sailors RM Moore FA Supra-normal trauma resuscitation causes more cases of abdominal compartment syndrome Arch Surg 138637-643 2003

bull Duchesne JC Heaney J Guidry C McSwain N Jr Meade P Cohen M Schreiber M Inaba K Skiada D Demetriades D Holcomb J Wade C Cotton B Diluting the benefits of hemostatic resuscitation A multi-institutional analysis J Trauma Acute Care Surg 2013 Jul75(1)76-82 doi 101097TA0b013e3182987df3

bull Guidry C Gleeson E Simms ER Stuke L Meade P McSwain NE Jr Duchesne JC Initial assessment on the impact of crystalloids versus colloids during damage control resuscitation J Surg Res 2013 Jun 15 pii S0022-4804(13)00568-4 doi 101016jjss201305086 [Epub ahead of print]

bull Perel P Roberts I Ker K Colloids versus crystalloids for fluid resuscitation in critically ill patients Cochrane Database Syst Rev 2013 Feb 282CD000567 doi 10100214651858CD000567pub6

bull Zarychanski R Abou-Setta AM Turgeon AF et al Association of Hydroxyethyl Starch Administration With Mortality and Acute Kidney Injury in Critically Ill Patients Requiring Volume Resuscitation A Systematic Review and Meta-analysis JAMA 2013309(7)678-688 doi101001jama2013430

bull Bulger EM May S Kerby JD Emerson S Stiell IG Schreiber MA Brasel KJ Tisherman SA Coimbra R Rizoli S Minei JP Hata JS Sopko G Evans DC Hoyt DB ROC investigators Out-of-hospital hypertonic resuscitation after traumatic hypovolemic shock a randomized placebo controlled trial Ann Surg 2011 Mar253(3)431-41 doi 101097SLA0b013e3181fcdb22

bull Vassar MJ Fischer RP OBrien PE Bachulis BL Chambers JA Hoyt DB Holcroft JW A multicenter trial for resuscitation of injured patients with 75 sodium chloride The effect of added dextran 70 The Multicenter Group for the Study of Hypertonic Saline in Trauma Patients Arch Surg 1993 Sep128(9)1003-11 discussion 1011-3

bull Cooper DJ Myles PS McDermott FT Murray LJ Laidlaw J Cooper G Tremayne AB Bernard SS Ponsford J HTS Study Investigators Prehospital hypertonic saline resuscitation of patients with hypotension and severe traumatic brain injury a randomized controlled trial JAMA 2004 Mar 17291(11)1350-7

bull Duke MD Guidry C Guice J Stuke L Marr AB Hunt JP Meade P McSwain NE Jr Duchesne JC Restrictive fluid resuscitation in combination with damage control resuscitation time for adaptation J Trauma Acute Care Surg 2012 Sep73(3)674-8 doi 101097TA0b013e318265ce1f

bull Pidcoke HF Aden JK Mora AG Borgman MA Spinella PC Dubick MA Blackbourne LH Cap AP Ten-year analysis of transfusion in Operation Iraqi Freedom and Operation Enduring Freedom increased plasma and platelet use correlates with improved survival J Trauma Acute Care Surg 2012 Dec73(6 Suppl 5)S445-52 doi 101097TA0b013e3182754796

bull Morrison CA Carrick MM Norman MA Scott BG Welsh FJ Tsai P Liscum KR Wall MJ Jr Mattox KL Hypotensive resuscitation strategy reduces transfusion requirements and severe postoperative coagulopathy in trauma patients with hemorrhagic shock preliminary results of a randomized controlled trial J Trauma 2011 Mar70(3)652-63 doi 101097TA0b013e31820e77ea

bull Ley EJ Clond MA Srour MK Barnajian M Mirocha J Margulies DR Salim A Emergency department crystalloid resuscitation of 15 L or more is associated with increased mortality in elderly and nonelderly trauma patients J Trauma 2011 Feb70(2)398-400 doi 101097TA0b013e318208f99b

bull Kasotakis G Sideris A Yang Y de Moya M Alam H King DR Tompkins R Velmahos G Inflammation and Host Response to Injury Investigators Aggressive early crystalloid resuscitation adversely affects outcomes in adult blunt trauma patients an analysis of the Glue Grant database J Trauma Acute Care Surg 2013 May74(5)1215-21 discussion 1221-2 doi 101097TA0b013e3182826e13

bull Neal MD Hoffman MK Cuschieri J Minei JP Maier RV Harbrecht BG Billiar TR Peitzman AB Moore EE Cohen MJ Sperry JL Crystalloid to packed red blood cell transfusion ratio in the massively transfused patient when a little goes a long way J Trauma Acute Care Surg 2012 Apr72(4)892-8 doi 101097TA0b013e31823d84a7

bull Niles SE McLaughlin DF Perkins JG et al Increased mortality associated with the early coagulopathy of trauma in combat casualties J Trauma 2008641459-63

bull Brohi K Singh J Heron M Coats T Acute traumatic coagulopathy J Trauma 2003541127-30

bull Cotton BA Gunter OL Isbell J et al Damage control hematology the impact of a trauma exsanguination protocol on survival and blood product utilization J Trauma 2008641177-82

bull Keneally RJ1 Parsons AM1 Willett PB1 Warm fresh whole blood and thoracic traumain iraq and afghanistan J Emerg Trauma Shock 2015 Jan-Mar8(1)21-5

bull Spinella PC1 Perkins JG Grathwohl KW Beekley AC Holcomb JB Warm fresh whole blood is independently associated with improved survival for patients with combat-related traumatic injuries J Trauma 2009 Apr66(4 Suppl)S69-76

bull Wafaisade A1 Lefering R2 Bouillon B3 Boumlhmer AB4 Gaumlszligler M5 Ruppert M5 TraumaRegister DGU Prehospital administration of tranexamic acid in trauma patients Crit Care 2016 May 1220(1)143

bull Ausset S1 Glassberg E Nadler R Sunde G Cap AP Hoffmann C Plang S Sailliol A Tranexamic acid as part of remote damage-control resuscitation in the prehospital setting A critical appraisal of the medical literature and available alternatives J Trauma Acute Care Surg 2015 Jun78(6 Suppl 1)S70-5

bull CRASH-2 trial collaborators Shakur H Roberts I Bautista R Caballero J Coats T Dewan Y El-Sayed H Gogichaishvili T Gupta S Herrera J Hunt B Iribhogbe P Izurieta M Khamis H Komolafe E Marrero MA Mejiacutea-Mantilla J Miranda J Morales C Olaomi O Olldashi F Perel P Peto R Ramana PV Ravi RR Yutthakasemsunt S Effects of tranexamic acid on death vascular occlusive events and blood transfusion in trauma patients with significant haemorrhage (CRASH-2) a randomised placebo-controlled trial Lancet 2010 Jul 3376(9734)23-32

bull Morrison JJ1 Dubose JJ Rasmussen TE Midwinter MJ Military Application of Tranexamic Acid in Trauma Emergency Resuscitation (MATTERs) Study Arch Surg 2012 Feb147(2)113-9

bull Morrison JJ1 Ross JD Dubose JJ Jansen JO Midwinter MJ Rasmussen TE Association of cryoprecipitate and tranexamic acid with improved survival following wartime injury findings from the MATTERs II Study JAMA Surg 2013 Mar148(3)218-25

Which should we give

first

bull We have decent oxygen carrying capacity when anemic

bull Plasma first transfusion may be better

bull Fix the coagulopathy hypothermia acidosis

bull Prehospital freeze dried plasma (FDP)

bull Being studied by US military

bull Used by our European colleagues

bull not FDA approved in the US currently

Fibrinogen

bull Fresh whole blood 1000 mg of fibrinogen

bull FFP 400 mg

bull Platelets 80 mg

bull Cryoprecipitate 2500 mg

bull Transfusion with high ratios of fibrinogen to RBCs have

shown survival benefit

Fresh Whole Blood

Blood

bull Fresh whole blood AT LEAST equivalent to components

bull May improve survival

bull Restricted fluid resuscitation (lt1500 mL crystalloid) OR

of death 069

bull DCR Less fluid (5 vs 14 L) less pRBCs (7 u vs 13 u)

less ldquolethal triadrdquo (46 vs 80) survival OR 25

TCCC Order of preference

for fluid resuscitation

bull Fresh whole blood

bull PRBCsFFPPlatelets in 111 ratio

bull PRBCsFFP in 11 ratio

bull PRBCs or FFP

bull Plasmalyte Normosol

bull Lactated Ringers

bull Not recommended Normal Saline

Tranexamic Acid

bull Antithrombolytic

bull ldquoHyperfibrinolysis of traumardquo

bull 1g over 10 min

bull Giving it faster can cause hypotension

bull May give up to 5g (studied up to 250mgkg)

bull Re-dose if hemorrhage is ongoing

Tranexamic Acid

bull CRASH-2 bull Given across a wide spectrum of trauma patients in 40 countries

bull ARR 15

bull Poorly controlled only half went to OR

bull MATTERs bull 17 vs 239 mortality

bull Benefit greatest in those getting MTP

bull MATTERs II bull TXA vs Cryo vs TXA+Cryo

bull 116 vs 236 mortality

bull Best benefit lt1h after injury

bull Some benefit lt3h after injury

bull Possible harm gt3h after injury

Tranexamic Acid

bull CRASH-2 TBI

bull Basically a wash

bull Cole Davenport Brohi TXA did not affect mortality in

overall or non-shock cohorts

bull MVA showed OR of MOF 027 and death 016

bull Valle Allen Higher mortality with TXA if needing gt2L

PRBCs

bull Given 97 min after ADMISSION and after transfusion

Factor VIIa

bull No studies showing mortality benefit

bull Studies showing decreased blood loss

bull $45000dose

bull May consider if still bleeding after TXA

Metabolic acidosis

bull Keep pH above 72

bull Administer THAM (Tromethamine solution) or sodium

bicarbonate to maintain pH

bull Weight in kg x base deficit x 11 = volume of THAM

solution to give (18g500mL)

bull Weight in kg x base deficit x 02 = volume of sodium

bicarb solution to give

Calcium

bull Calcium used up in clots

bull Calcium gobbled up by citrate in stored blood

bull Maintain ionized iCa gt 10 (run on ABG machine)

bull 1g Ca Gluconate for every 4 u FFP

Storage lesions

bull Stored blood is acidic

bull Calcium is chelated by preservatives

bull Platelets decline in function

Thromboelastography

(TEG)

bull Gives a better picture of coagulation status

bull Measures time to initiate clot

bull Speed of formation

bull Strength of clot

bull Fibrinolysis

bull Can help guide transfusion therapy

bull Better outcomes at gt10u PRBCs

bull Fewer units of blood

TEG

TEG Value Transfuse

TEG-ACT gt 140 FFP

R time gt 10 FFP

K time gt 3 Cryo

A angle Cry +- Platelets

MA lt 50 Platelets

LY30 gt3 TXA

REBOA

bull Resuscitative Endovascular Balloon Occlusion of the

Aorta

ER REBOA

Bottom Line

bull Keep them WARM

bull Little to no crystalloid

bull Hypotension is bad for brain injuries

bull Think about MT early

bull 111 ratio

bull Give TXA early

bull Calcium

bull Fix acidosis

bull Balogh Z McKinley BA Cocanour CS Kozar RA Valdivia A Sailors RM Moore FA Supra-normal trauma resuscitation causes more cases of abdominal compartment syndrome Arch Surg 138637-643 2003

bull Duchesne JC Heaney J Guidry C McSwain N Jr Meade P Cohen M Schreiber M Inaba K Skiada D Demetriades D Holcomb J Wade C Cotton B Diluting the benefits of hemostatic resuscitation A multi-institutional analysis J Trauma Acute Care Surg 2013 Jul75(1)76-82 doi 101097TA0b013e3182987df3

bull Guidry C Gleeson E Simms ER Stuke L Meade P McSwain NE Jr Duchesne JC Initial assessment on the impact of crystalloids versus colloids during damage control resuscitation J Surg Res 2013 Jun 15 pii S0022-4804(13)00568-4 doi 101016jjss201305086 [Epub ahead of print]

bull Perel P Roberts I Ker K Colloids versus crystalloids for fluid resuscitation in critically ill patients Cochrane Database Syst Rev 2013 Feb 282CD000567 doi 10100214651858CD000567pub6

bull Zarychanski R Abou-Setta AM Turgeon AF et al Association of Hydroxyethyl Starch Administration With Mortality and Acute Kidney Injury in Critically Ill Patients Requiring Volume Resuscitation A Systematic Review and Meta-analysis JAMA 2013309(7)678-688 doi101001jama2013430

bull Bulger EM May S Kerby JD Emerson S Stiell IG Schreiber MA Brasel KJ Tisherman SA Coimbra R Rizoli S Minei JP Hata JS Sopko G Evans DC Hoyt DB ROC investigators Out-of-hospital hypertonic resuscitation after traumatic hypovolemic shock a randomized placebo controlled trial Ann Surg 2011 Mar253(3)431-41 doi 101097SLA0b013e3181fcdb22

bull Vassar MJ Fischer RP OBrien PE Bachulis BL Chambers JA Hoyt DB Holcroft JW A multicenter trial for resuscitation of injured patients with 75 sodium chloride The effect of added dextran 70 The Multicenter Group for the Study of Hypertonic Saline in Trauma Patients Arch Surg 1993 Sep128(9)1003-11 discussion 1011-3

bull Cooper DJ Myles PS McDermott FT Murray LJ Laidlaw J Cooper G Tremayne AB Bernard SS Ponsford J HTS Study Investigators Prehospital hypertonic saline resuscitation of patients with hypotension and severe traumatic brain injury a randomized controlled trial JAMA 2004 Mar 17291(11)1350-7

bull Duke MD Guidry C Guice J Stuke L Marr AB Hunt JP Meade P McSwain NE Jr Duchesne JC Restrictive fluid resuscitation in combination with damage control resuscitation time for adaptation J Trauma Acute Care Surg 2012 Sep73(3)674-8 doi 101097TA0b013e318265ce1f

bull Pidcoke HF Aden JK Mora AG Borgman MA Spinella PC Dubick MA Blackbourne LH Cap AP Ten-year analysis of transfusion in Operation Iraqi Freedom and Operation Enduring Freedom increased plasma and platelet use correlates with improved survival J Trauma Acute Care Surg 2012 Dec73(6 Suppl 5)S445-52 doi 101097TA0b013e3182754796

bull Morrison CA Carrick MM Norman MA Scott BG Welsh FJ Tsai P Liscum KR Wall MJ Jr Mattox KL Hypotensive resuscitation strategy reduces transfusion requirements and severe postoperative coagulopathy in trauma patients with hemorrhagic shock preliminary results of a randomized controlled trial J Trauma 2011 Mar70(3)652-63 doi 101097TA0b013e31820e77ea

bull Ley EJ Clond MA Srour MK Barnajian M Mirocha J Margulies DR Salim A Emergency department crystalloid resuscitation of 15 L or more is associated with increased mortality in elderly and nonelderly trauma patients J Trauma 2011 Feb70(2)398-400 doi 101097TA0b013e318208f99b

bull Kasotakis G Sideris A Yang Y de Moya M Alam H King DR Tompkins R Velmahos G Inflammation and Host Response to Injury Investigators Aggressive early crystalloid resuscitation adversely affects outcomes in adult blunt trauma patients an analysis of the Glue Grant database J Trauma Acute Care Surg 2013 May74(5)1215-21 discussion 1221-2 doi 101097TA0b013e3182826e13

bull Neal MD Hoffman MK Cuschieri J Minei JP Maier RV Harbrecht BG Billiar TR Peitzman AB Moore EE Cohen MJ Sperry JL Crystalloid to packed red blood cell transfusion ratio in the massively transfused patient when a little goes a long way J Trauma Acute Care Surg 2012 Apr72(4)892-8 doi 101097TA0b013e31823d84a7

bull Niles SE McLaughlin DF Perkins JG et al Increased mortality associated with the early coagulopathy of trauma in combat casualties J Trauma 2008641459-63

bull Brohi K Singh J Heron M Coats T Acute traumatic coagulopathy J Trauma 2003541127-30

bull Cotton BA Gunter OL Isbell J et al Damage control hematology the impact of a trauma exsanguination protocol on survival and blood product utilization J Trauma 2008641177-82

bull Keneally RJ1 Parsons AM1 Willett PB1 Warm fresh whole blood and thoracic traumain iraq and afghanistan J Emerg Trauma Shock 2015 Jan-Mar8(1)21-5

bull Spinella PC1 Perkins JG Grathwohl KW Beekley AC Holcomb JB Warm fresh whole blood is independently associated with improved survival for patients with combat-related traumatic injuries J Trauma 2009 Apr66(4 Suppl)S69-76

bull Wafaisade A1 Lefering R2 Bouillon B3 Boumlhmer AB4 Gaumlszligler M5 Ruppert M5 TraumaRegister DGU Prehospital administration of tranexamic acid in trauma patients Crit Care 2016 May 1220(1)143

bull Ausset S1 Glassberg E Nadler R Sunde G Cap AP Hoffmann C Plang S Sailliol A Tranexamic acid as part of remote damage-control resuscitation in the prehospital setting A critical appraisal of the medical literature and available alternatives J Trauma Acute Care Surg 2015 Jun78(6 Suppl 1)S70-5

bull CRASH-2 trial collaborators Shakur H Roberts I Bautista R Caballero J Coats T Dewan Y El-Sayed H Gogichaishvili T Gupta S Herrera J Hunt B Iribhogbe P Izurieta M Khamis H Komolafe E Marrero MA Mejiacutea-Mantilla J Miranda J Morales C Olaomi O Olldashi F Perel P Peto R Ramana PV Ravi RR Yutthakasemsunt S Effects of tranexamic acid on death vascular occlusive events and blood transfusion in trauma patients with significant haemorrhage (CRASH-2) a randomised placebo-controlled trial Lancet 2010 Jul 3376(9734)23-32

bull Morrison JJ1 Dubose JJ Rasmussen TE Midwinter MJ Military Application of Tranexamic Acid in Trauma Emergency Resuscitation (MATTERs) Study Arch Surg 2012 Feb147(2)113-9

bull Morrison JJ1 Ross JD Dubose JJ Jansen JO Midwinter MJ Rasmussen TE Association of cryoprecipitate and tranexamic acid with improved survival following wartime injury findings from the MATTERs II Study JAMA Surg 2013 Mar148(3)218-25

Fibrinogen

bull Fresh whole blood 1000 mg of fibrinogen

bull FFP 400 mg

bull Platelets 80 mg

bull Cryoprecipitate 2500 mg

bull Transfusion with high ratios of fibrinogen to RBCs have

shown survival benefit

Fresh Whole Blood

Blood

bull Fresh whole blood AT LEAST equivalent to components

bull May improve survival

bull Restricted fluid resuscitation (lt1500 mL crystalloid) OR

of death 069

bull DCR Less fluid (5 vs 14 L) less pRBCs (7 u vs 13 u)

less ldquolethal triadrdquo (46 vs 80) survival OR 25

TCCC Order of preference

for fluid resuscitation

bull Fresh whole blood

bull PRBCsFFPPlatelets in 111 ratio

bull PRBCsFFP in 11 ratio

bull PRBCs or FFP

bull Plasmalyte Normosol

bull Lactated Ringers

bull Not recommended Normal Saline

Tranexamic Acid

bull Antithrombolytic

bull ldquoHyperfibrinolysis of traumardquo

bull 1g over 10 min

bull Giving it faster can cause hypotension

bull May give up to 5g (studied up to 250mgkg)

bull Re-dose if hemorrhage is ongoing

Tranexamic Acid

bull CRASH-2 bull Given across a wide spectrum of trauma patients in 40 countries

bull ARR 15

bull Poorly controlled only half went to OR

bull MATTERs bull 17 vs 239 mortality

bull Benefit greatest in those getting MTP

bull MATTERs II bull TXA vs Cryo vs TXA+Cryo

bull 116 vs 236 mortality

bull Best benefit lt1h after injury

bull Some benefit lt3h after injury

bull Possible harm gt3h after injury

Tranexamic Acid

bull CRASH-2 TBI

bull Basically a wash

bull Cole Davenport Brohi TXA did not affect mortality in

overall or non-shock cohorts

bull MVA showed OR of MOF 027 and death 016

bull Valle Allen Higher mortality with TXA if needing gt2L

PRBCs

bull Given 97 min after ADMISSION and after transfusion

Factor VIIa

bull No studies showing mortality benefit

bull Studies showing decreased blood loss

bull $45000dose

bull May consider if still bleeding after TXA

Metabolic acidosis

bull Keep pH above 72

bull Administer THAM (Tromethamine solution) or sodium

bicarbonate to maintain pH

bull Weight in kg x base deficit x 11 = volume of THAM

solution to give (18g500mL)

bull Weight in kg x base deficit x 02 = volume of sodium

bicarb solution to give

Calcium

bull Calcium used up in clots

bull Calcium gobbled up by citrate in stored blood

bull Maintain ionized iCa gt 10 (run on ABG machine)

bull 1g Ca Gluconate for every 4 u FFP

Storage lesions

bull Stored blood is acidic

bull Calcium is chelated by preservatives

bull Platelets decline in function

Thromboelastography

(TEG)

bull Gives a better picture of coagulation status

bull Measures time to initiate clot

bull Speed of formation

bull Strength of clot

bull Fibrinolysis

bull Can help guide transfusion therapy

bull Better outcomes at gt10u PRBCs

bull Fewer units of blood

TEG

TEG Value Transfuse

TEG-ACT gt 140 FFP

R time gt 10 FFP

K time gt 3 Cryo

A angle Cry +- Platelets

MA lt 50 Platelets

LY30 gt3 TXA

REBOA

bull Resuscitative Endovascular Balloon Occlusion of the

Aorta

ER REBOA

Bottom Line

bull Keep them WARM

bull Little to no crystalloid

bull Hypotension is bad for brain injuries

bull Think about MT early

bull 111 ratio

bull Give TXA early

bull Calcium

bull Fix acidosis

bull Balogh Z McKinley BA Cocanour CS Kozar RA Valdivia A Sailors RM Moore FA Supra-normal trauma resuscitation causes more cases of abdominal compartment syndrome Arch Surg 138637-643 2003

bull Duchesne JC Heaney J Guidry C McSwain N Jr Meade P Cohen M Schreiber M Inaba K Skiada D Demetriades D Holcomb J Wade C Cotton B Diluting the benefits of hemostatic resuscitation A multi-institutional analysis J Trauma Acute Care Surg 2013 Jul75(1)76-82 doi 101097TA0b013e3182987df3

bull Guidry C Gleeson E Simms ER Stuke L Meade P McSwain NE Jr Duchesne JC Initial assessment on the impact of crystalloids versus colloids during damage control resuscitation J Surg Res 2013 Jun 15 pii S0022-4804(13)00568-4 doi 101016jjss201305086 [Epub ahead of print]

bull Perel P Roberts I Ker K Colloids versus crystalloids for fluid resuscitation in critically ill patients Cochrane Database Syst Rev 2013 Feb 282CD000567 doi 10100214651858CD000567pub6

bull Zarychanski R Abou-Setta AM Turgeon AF et al Association of Hydroxyethyl Starch Administration With Mortality and Acute Kidney Injury in Critically Ill Patients Requiring Volume Resuscitation A Systematic Review and Meta-analysis JAMA 2013309(7)678-688 doi101001jama2013430

bull Bulger EM May S Kerby JD Emerson S Stiell IG Schreiber MA Brasel KJ Tisherman SA Coimbra R Rizoli S Minei JP Hata JS Sopko G Evans DC Hoyt DB ROC investigators Out-of-hospital hypertonic resuscitation after traumatic hypovolemic shock a randomized placebo controlled trial Ann Surg 2011 Mar253(3)431-41 doi 101097SLA0b013e3181fcdb22

bull Vassar MJ Fischer RP OBrien PE Bachulis BL Chambers JA Hoyt DB Holcroft JW A multicenter trial for resuscitation of injured patients with 75 sodium chloride The effect of added dextran 70 The Multicenter Group for the Study of Hypertonic Saline in Trauma Patients Arch Surg 1993 Sep128(9)1003-11 discussion 1011-3

bull Cooper DJ Myles PS McDermott FT Murray LJ Laidlaw J Cooper G Tremayne AB Bernard SS Ponsford J HTS Study Investigators Prehospital hypertonic saline resuscitation of patients with hypotension and severe traumatic brain injury a randomized controlled trial JAMA 2004 Mar 17291(11)1350-7

bull Duke MD Guidry C Guice J Stuke L Marr AB Hunt JP Meade P McSwain NE Jr Duchesne JC Restrictive fluid resuscitation in combination with damage control resuscitation time for adaptation J Trauma Acute Care Surg 2012 Sep73(3)674-8 doi 101097TA0b013e318265ce1f

bull Pidcoke HF Aden JK Mora AG Borgman MA Spinella PC Dubick MA Blackbourne LH Cap AP Ten-year analysis of transfusion in Operation Iraqi Freedom and Operation Enduring Freedom increased plasma and platelet use correlates with improved survival J Trauma Acute Care Surg 2012 Dec73(6 Suppl 5)S445-52 doi 101097TA0b013e3182754796

bull Morrison CA Carrick MM Norman MA Scott BG Welsh FJ Tsai P Liscum KR Wall MJ Jr Mattox KL Hypotensive resuscitation strategy reduces transfusion requirements and severe postoperative coagulopathy in trauma patients with hemorrhagic shock preliminary results of a randomized controlled trial J Trauma 2011 Mar70(3)652-63 doi 101097TA0b013e31820e77ea

bull Ley EJ Clond MA Srour MK Barnajian M Mirocha J Margulies DR Salim A Emergency department crystalloid resuscitation of 15 L or more is associated with increased mortality in elderly and nonelderly trauma patients J Trauma 2011 Feb70(2)398-400 doi 101097TA0b013e318208f99b

bull Kasotakis G Sideris A Yang Y de Moya M Alam H King DR Tompkins R Velmahos G Inflammation and Host Response to Injury Investigators Aggressive early crystalloid resuscitation adversely affects outcomes in adult blunt trauma patients an analysis of the Glue Grant database J Trauma Acute Care Surg 2013 May74(5)1215-21 discussion 1221-2 doi 101097TA0b013e3182826e13

bull Neal MD Hoffman MK Cuschieri J Minei JP Maier RV Harbrecht BG Billiar TR Peitzman AB Moore EE Cohen MJ Sperry JL Crystalloid to packed red blood cell transfusion ratio in the massively transfused patient when a little goes a long way J Trauma Acute Care Surg 2012 Apr72(4)892-8 doi 101097TA0b013e31823d84a7

bull Niles SE McLaughlin DF Perkins JG et al Increased mortality associated with the early coagulopathy of trauma in combat casualties J Trauma 2008641459-63

bull Brohi K Singh J Heron M Coats T Acute traumatic coagulopathy J Trauma 2003541127-30

bull Cotton BA Gunter OL Isbell J et al Damage control hematology the impact of a trauma exsanguination protocol on survival and blood product utilization J Trauma 2008641177-82

bull Keneally RJ1 Parsons AM1 Willett PB1 Warm fresh whole blood and thoracic traumain iraq and afghanistan J Emerg Trauma Shock 2015 Jan-Mar8(1)21-5

bull Spinella PC1 Perkins JG Grathwohl KW Beekley AC Holcomb JB Warm fresh whole blood is independently associated with improved survival for patients with combat-related traumatic injuries J Trauma 2009 Apr66(4 Suppl)S69-76

bull Wafaisade A1 Lefering R2 Bouillon B3 Boumlhmer AB4 Gaumlszligler M5 Ruppert M5 TraumaRegister DGU Prehospital administration of tranexamic acid in trauma patients Crit Care 2016 May 1220(1)143

bull Ausset S1 Glassberg E Nadler R Sunde G Cap AP Hoffmann C Plang S Sailliol A Tranexamic acid as part of remote damage-control resuscitation in the prehospital setting A critical appraisal of the medical literature and available alternatives J Trauma Acute Care Surg 2015 Jun78(6 Suppl 1)S70-5

bull CRASH-2 trial collaborators Shakur H Roberts I Bautista R Caballero J Coats T Dewan Y El-Sayed H Gogichaishvili T Gupta S Herrera J Hunt B Iribhogbe P Izurieta M Khamis H Komolafe E Marrero MA Mejiacutea-Mantilla J Miranda J Morales C Olaomi O Olldashi F Perel P Peto R Ramana PV Ravi RR Yutthakasemsunt S Effects of tranexamic acid on death vascular occlusive events and blood transfusion in trauma patients with significant haemorrhage (CRASH-2) a randomised placebo-controlled trial Lancet 2010 Jul 3376(9734)23-32

bull Morrison JJ1 Dubose JJ Rasmussen TE Midwinter MJ Military Application of Tranexamic Acid in Trauma Emergency Resuscitation (MATTERs) Study Arch Surg 2012 Feb147(2)113-9

bull Morrison JJ1 Ross JD Dubose JJ Jansen JO Midwinter MJ Rasmussen TE Association of cryoprecipitate and tranexamic acid with improved survival following wartime injury findings from the MATTERs II Study JAMA Surg 2013 Mar148(3)218-25

Fresh Whole Blood

Blood

bull Fresh whole blood AT LEAST equivalent to components

bull May improve survival

bull Restricted fluid resuscitation (lt1500 mL crystalloid) OR

of death 069

bull DCR Less fluid (5 vs 14 L) less pRBCs (7 u vs 13 u)

less ldquolethal triadrdquo (46 vs 80) survival OR 25

TCCC Order of preference

for fluid resuscitation

bull Fresh whole blood

bull PRBCsFFPPlatelets in 111 ratio

bull PRBCsFFP in 11 ratio

bull PRBCs or FFP

bull Plasmalyte Normosol

bull Lactated Ringers

bull Not recommended Normal Saline

Tranexamic Acid

bull Antithrombolytic

bull ldquoHyperfibrinolysis of traumardquo

bull 1g over 10 min

bull Giving it faster can cause hypotension

bull May give up to 5g (studied up to 250mgkg)

bull Re-dose if hemorrhage is ongoing

Tranexamic Acid

bull CRASH-2 bull Given across a wide spectrum of trauma patients in 40 countries

bull ARR 15

bull Poorly controlled only half went to OR

bull MATTERs bull 17 vs 239 mortality

bull Benefit greatest in those getting MTP

bull MATTERs II bull TXA vs Cryo vs TXA+Cryo

bull 116 vs 236 mortality

bull Best benefit lt1h after injury

bull Some benefit lt3h after injury

bull Possible harm gt3h after injury

Tranexamic Acid

bull CRASH-2 TBI

bull Basically a wash

bull Cole Davenport Brohi TXA did not affect mortality in

overall or non-shock cohorts

bull MVA showed OR of MOF 027 and death 016

bull Valle Allen Higher mortality with TXA if needing gt2L

PRBCs

bull Given 97 min after ADMISSION and after transfusion

Factor VIIa

bull No studies showing mortality benefit

bull Studies showing decreased blood loss

bull $45000dose

bull May consider if still bleeding after TXA

Metabolic acidosis

bull Keep pH above 72

bull Administer THAM (Tromethamine solution) or sodium

bicarbonate to maintain pH

bull Weight in kg x base deficit x 11 = volume of THAM

solution to give (18g500mL)

bull Weight in kg x base deficit x 02 = volume of sodium

bicarb solution to give

Calcium

bull Calcium used up in clots

bull Calcium gobbled up by citrate in stored blood

bull Maintain ionized iCa gt 10 (run on ABG machine)

bull 1g Ca Gluconate for every 4 u FFP

Storage lesions

bull Stored blood is acidic

bull Calcium is chelated by preservatives

bull Platelets decline in function

Thromboelastography

(TEG)

bull Gives a better picture of coagulation status

bull Measures time to initiate clot

bull Speed of formation

bull Strength of clot

bull Fibrinolysis

bull Can help guide transfusion therapy

bull Better outcomes at gt10u PRBCs

bull Fewer units of blood

TEG

TEG Value Transfuse

TEG-ACT gt 140 FFP

R time gt 10 FFP

K time gt 3 Cryo

A angle Cry +- Platelets

MA lt 50 Platelets

LY30 gt3 TXA

REBOA

bull Resuscitative Endovascular Balloon Occlusion of the

Aorta

ER REBOA

Bottom Line

bull Keep them WARM

bull Little to no crystalloid

bull Hypotension is bad for brain injuries

bull Think about MT early

bull 111 ratio

bull Give TXA early

bull Calcium

bull Fix acidosis

bull Balogh Z McKinley BA Cocanour CS Kozar RA Valdivia A Sailors RM Moore FA Supra-normal trauma resuscitation causes more cases of abdominal compartment syndrome Arch Surg 138637-643 2003

bull Duchesne JC Heaney J Guidry C McSwain N Jr Meade P Cohen M Schreiber M Inaba K Skiada D Demetriades D Holcomb J Wade C Cotton B Diluting the benefits of hemostatic resuscitation A multi-institutional analysis J Trauma Acute Care Surg 2013 Jul75(1)76-82 doi 101097TA0b013e3182987df3

bull Guidry C Gleeson E Simms ER Stuke L Meade P McSwain NE Jr Duchesne JC Initial assessment on the impact of crystalloids versus colloids during damage control resuscitation J Surg Res 2013 Jun 15 pii S0022-4804(13)00568-4 doi 101016jjss201305086 [Epub ahead of print]

bull Perel P Roberts I Ker K Colloids versus crystalloids for fluid resuscitation in critically ill patients Cochrane Database Syst Rev 2013 Feb 282CD000567 doi 10100214651858CD000567pub6

bull Zarychanski R Abou-Setta AM Turgeon AF et al Association of Hydroxyethyl Starch Administration With Mortality and Acute Kidney Injury in Critically Ill Patients Requiring Volume Resuscitation A Systematic Review and Meta-analysis JAMA 2013309(7)678-688 doi101001jama2013430

bull Bulger EM May S Kerby JD Emerson S Stiell IG Schreiber MA Brasel KJ Tisherman SA Coimbra R Rizoli S Minei JP Hata JS Sopko G Evans DC Hoyt DB ROC investigators Out-of-hospital hypertonic resuscitation after traumatic hypovolemic shock a randomized placebo controlled trial Ann Surg 2011 Mar253(3)431-41 doi 101097SLA0b013e3181fcdb22

bull Vassar MJ Fischer RP OBrien PE Bachulis BL Chambers JA Hoyt DB Holcroft JW A multicenter trial for resuscitation of injured patients with 75 sodium chloride The effect of added dextran 70 The Multicenter Group for the Study of Hypertonic Saline in Trauma Patients Arch Surg 1993 Sep128(9)1003-11 discussion 1011-3

bull Cooper DJ Myles PS McDermott FT Murray LJ Laidlaw J Cooper G Tremayne AB Bernard SS Ponsford J HTS Study Investigators Prehospital hypertonic saline resuscitation of patients with hypotension and severe traumatic brain injury a randomized controlled trial JAMA 2004 Mar 17291(11)1350-7

bull Duke MD Guidry C Guice J Stuke L Marr AB Hunt JP Meade P McSwain NE Jr Duchesne JC Restrictive fluid resuscitation in combination with damage control resuscitation time for adaptation J Trauma Acute Care Surg 2012 Sep73(3)674-8 doi 101097TA0b013e318265ce1f

bull Pidcoke HF Aden JK Mora AG Borgman MA Spinella PC Dubick MA Blackbourne LH Cap AP Ten-year analysis of transfusion in Operation Iraqi Freedom and Operation Enduring Freedom increased plasma and platelet use correlates with improved survival J Trauma Acute Care Surg 2012 Dec73(6 Suppl 5)S445-52 doi 101097TA0b013e3182754796

bull Morrison CA Carrick MM Norman MA Scott BG Welsh FJ Tsai P Liscum KR Wall MJ Jr Mattox KL Hypotensive resuscitation strategy reduces transfusion requirements and severe postoperative coagulopathy in trauma patients with hemorrhagic shock preliminary results of a randomized controlled trial J Trauma 2011 Mar70(3)652-63 doi 101097TA0b013e31820e77ea

bull Ley EJ Clond MA Srour MK Barnajian M Mirocha J Margulies DR Salim A Emergency department crystalloid resuscitation of 15 L or more is associated with increased mortality in elderly and nonelderly trauma patients J Trauma 2011 Feb70(2)398-400 doi 101097TA0b013e318208f99b

bull Kasotakis G Sideris A Yang Y de Moya M Alam H King DR Tompkins R Velmahos G Inflammation and Host Response to Injury Investigators Aggressive early crystalloid resuscitation adversely affects outcomes in adult blunt trauma patients an analysis of the Glue Grant database J Trauma Acute Care Surg 2013 May74(5)1215-21 discussion 1221-2 doi 101097TA0b013e3182826e13

bull Neal MD Hoffman MK Cuschieri J Minei JP Maier RV Harbrecht BG Billiar TR Peitzman AB Moore EE Cohen MJ Sperry JL Crystalloid to packed red blood cell transfusion ratio in the massively transfused patient when a little goes a long way J Trauma Acute Care Surg 2012 Apr72(4)892-8 doi 101097TA0b013e31823d84a7

bull Niles SE McLaughlin DF Perkins JG et al Increased mortality associated with the early coagulopathy of trauma in combat casualties J Trauma 2008641459-63

bull Brohi K Singh J Heron M Coats T Acute traumatic coagulopathy J Trauma 2003541127-30

bull Cotton BA Gunter OL Isbell J et al Damage control hematology the impact of a trauma exsanguination protocol on survival and blood product utilization J Trauma 2008641177-82

bull Keneally RJ1 Parsons AM1 Willett PB1 Warm fresh whole blood and thoracic traumain iraq and afghanistan J Emerg Trauma Shock 2015 Jan-Mar8(1)21-5

bull Spinella PC1 Perkins JG Grathwohl KW Beekley AC Holcomb JB Warm fresh whole blood is independently associated with improved survival for patients with combat-related traumatic injuries J Trauma 2009 Apr66(4 Suppl)S69-76

bull Wafaisade A1 Lefering R2 Bouillon B3 Boumlhmer AB4 Gaumlszligler M5 Ruppert M5 TraumaRegister DGU Prehospital administration of tranexamic acid in trauma patients Crit Care 2016 May 1220(1)143

bull Ausset S1 Glassberg E Nadler R Sunde G Cap AP Hoffmann C Plang S Sailliol A Tranexamic acid as part of remote damage-control resuscitation in the prehospital setting A critical appraisal of the medical literature and available alternatives J Trauma Acute Care Surg 2015 Jun78(6 Suppl 1)S70-5

bull CRASH-2 trial collaborators Shakur H Roberts I Bautista R Caballero J Coats T Dewan Y El-Sayed H Gogichaishvili T Gupta S Herrera J Hunt B Iribhogbe P Izurieta M Khamis H Komolafe E Marrero MA Mejiacutea-Mantilla J Miranda J Morales C Olaomi O Olldashi F Perel P Peto R Ramana PV Ravi RR Yutthakasemsunt S Effects of tranexamic acid on death vascular occlusive events and blood transfusion in trauma patients with significant haemorrhage (CRASH-2) a randomised placebo-controlled trial Lancet 2010 Jul 3376(9734)23-32

bull Morrison JJ1 Dubose JJ Rasmussen TE Midwinter MJ Military Application of Tranexamic Acid in Trauma Emergency Resuscitation (MATTERs) Study Arch Surg 2012 Feb147(2)113-9

bull Morrison JJ1 Ross JD Dubose JJ Jansen JO Midwinter MJ Rasmussen TE Association of cryoprecipitate and tranexamic acid with improved survival following wartime injury findings from the MATTERs II Study JAMA Surg 2013 Mar148(3)218-25

Blood

bull Fresh whole blood AT LEAST equivalent to components

bull May improve survival

bull Restricted fluid resuscitation (lt1500 mL crystalloid) OR

of death 069

bull DCR Less fluid (5 vs 14 L) less pRBCs (7 u vs 13 u)

less ldquolethal triadrdquo (46 vs 80) survival OR 25

TCCC Order of preference

for fluid resuscitation

bull Fresh whole blood

bull PRBCsFFPPlatelets in 111 ratio

bull PRBCsFFP in 11 ratio

bull PRBCs or FFP

bull Plasmalyte Normosol

bull Lactated Ringers

bull Not recommended Normal Saline

Tranexamic Acid

bull Antithrombolytic

bull ldquoHyperfibrinolysis of traumardquo

bull 1g over 10 min

bull Giving it faster can cause hypotension

bull May give up to 5g (studied up to 250mgkg)

bull Re-dose if hemorrhage is ongoing

Tranexamic Acid

bull CRASH-2 bull Given across a wide spectrum of trauma patients in 40 countries

bull ARR 15

bull Poorly controlled only half went to OR

bull MATTERs bull 17 vs 239 mortality

bull Benefit greatest in those getting MTP

bull MATTERs II bull TXA vs Cryo vs TXA+Cryo

bull 116 vs 236 mortality

bull Best benefit lt1h after injury

bull Some benefit lt3h after injury

bull Possible harm gt3h after injury

Tranexamic Acid

bull CRASH-2 TBI

bull Basically a wash

bull Cole Davenport Brohi TXA did not affect mortality in

overall or non-shock cohorts

bull MVA showed OR of MOF 027 and death 016

bull Valle Allen Higher mortality with TXA if needing gt2L

PRBCs

bull Given 97 min after ADMISSION and after transfusion

Factor VIIa

bull No studies showing mortality benefit

bull Studies showing decreased blood loss

bull $45000dose

bull May consider if still bleeding after TXA

Metabolic acidosis

bull Keep pH above 72

bull Administer THAM (Tromethamine solution) or sodium

bicarbonate to maintain pH

bull Weight in kg x base deficit x 11 = volume of THAM

solution to give (18g500mL)

bull Weight in kg x base deficit x 02 = volume of sodium

bicarb solution to give

Calcium

bull Calcium used up in clots

bull Calcium gobbled up by citrate in stored blood

bull Maintain ionized iCa gt 10 (run on ABG machine)

bull 1g Ca Gluconate for every 4 u FFP

Storage lesions

bull Stored blood is acidic

bull Calcium is chelated by preservatives

bull Platelets decline in function

Thromboelastography

(TEG)

bull Gives a better picture of coagulation status

bull Measures time to initiate clot

bull Speed of formation

bull Strength of clot

bull Fibrinolysis

bull Can help guide transfusion therapy

bull Better outcomes at gt10u PRBCs

bull Fewer units of blood

TEG

TEG Value Transfuse

TEG-ACT gt 140 FFP

R time gt 10 FFP

K time gt 3 Cryo

A angle Cry +- Platelets

MA lt 50 Platelets

LY30 gt3 TXA

REBOA

bull Resuscitative Endovascular Balloon Occlusion of the

Aorta

ER REBOA

Bottom Line

bull Keep them WARM

bull Little to no crystalloid

bull Hypotension is bad for brain injuries

bull Think about MT early

bull 111 ratio

bull Give TXA early

bull Calcium

bull Fix acidosis

bull Balogh Z McKinley BA Cocanour CS Kozar RA Valdivia A Sailors RM Moore FA Supra-normal trauma resuscitation causes more cases of abdominal compartment syndrome Arch Surg 138637-643 2003

bull Duchesne JC Heaney J Guidry C McSwain N Jr Meade P Cohen M Schreiber M Inaba K Skiada D Demetriades D Holcomb J Wade C Cotton B Diluting the benefits of hemostatic resuscitation A multi-institutional analysis J Trauma Acute Care Surg 2013 Jul75(1)76-82 doi 101097TA0b013e3182987df3

bull Guidry C Gleeson E Simms ER Stuke L Meade P McSwain NE Jr Duchesne JC Initial assessment on the impact of crystalloids versus colloids during damage control resuscitation J Surg Res 2013 Jun 15 pii S0022-4804(13)00568-4 doi 101016jjss201305086 [Epub ahead of print]

bull Perel P Roberts I Ker K Colloids versus crystalloids for fluid resuscitation in critically ill patients Cochrane Database Syst Rev 2013 Feb 282CD000567 doi 10100214651858CD000567pub6

bull Zarychanski R Abou-Setta AM Turgeon AF et al Association of Hydroxyethyl Starch Administration With Mortality and Acute Kidney Injury in Critically Ill Patients Requiring Volume Resuscitation A Systematic Review and Meta-analysis JAMA 2013309(7)678-688 doi101001jama2013430

bull Bulger EM May S Kerby JD Emerson S Stiell IG Schreiber MA Brasel KJ Tisherman SA Coimbra R Rizoli S Minei JP Hata JS Sopko G Evans DC Hoyt DB ROC investigators Out-of-hospital hypertonic resuscitation after traumatic hypovolemic shock a randomized placebo controlled trial Ann Surg 2011 Mar253(3)431-41 doi 101097SLA0b013e3181fcdb22

bull Vassar MJ Fischer RP OBrien PE Bachulis BL Chambers JA Hoyt DB Holcroft JW A multicenter trial for resuscitation of injured patients with 75 sodium chloride The effect of added dextran 70 The Multicenter Group for the Study of Hypertonic Saline in Trauma Patients Arch Surg 1993 Sep128(9)1003-11 discussion 1011-3

bull Cooper DJ Myles PS McDermott FT Murray LJ Laidlaw J Cooper G Tremayne AB Bernard SS Ponsford J HTS Study Investigators Prehospital hypertonic saline resuscitation of patients with hypotension and severe traumatic brain injury a randomized controlled trial JAMA 2004 Mar 17291(11)1350-7

bull Duke MD Guidry C Guice J Stuke L Marr AB Hunt JP Meade P McSwain NE Jr Duchesne JC Restrictive fluid resuscitation in combination with damage control resuscitation time for adaptation J Trauma Acute Care Surg 2012 Sep73(3)674-8 doi 101097TA0b013e318265ce1f

bull Pidcoke HF Aden JK Mora AG Borgman MA Spinella PC Dubick MA Blackbourne LH Cap AP Ten-year analysis of transfusion in Operation Iraqi Freedom and Operation Enduring Freedom increased plasma and platelet use correlates with improved survival J Trauma Acute Care Surg 2012 Dec73(6 Suppl 5)S445-52 doi 101097TA0b013e3182754796

bull Morrison CA Carrick MM Norman MA Scott BG Welsh FJ Tsai P Liscum KR Wall MJ Jr Mattox KL Hypotensive resuscitation strategy reduces transfusion requirements and severe postoperative coagulopathy in trauma patients with hemorrhagic shock preliminary results of a randomized controlled trial J Trauma 2011 Mar70(3)652-63 doi 101097TA0b013e31820e77ea

bull Ley EJ Clond MA Srour MK Barnajian M Mirocha J Margulies DR Salim A Emergency department crystalloid resuscitation of 15 L or more is associated with increased mortality in elderly and nonelderly trauma patients J Trauma 2011 Feb70(2)398-400 doi 101097TA0b013e318208f99b

bull Kasotakis G Sideris A Yang Y de Moya M Alam H King DR Tompkins R Velmahos G Inflammation and Host Response to Injury Investigators Aggressive early crystalloid resuscitation adversely affects outcomes in adult blunt trauma patients an analysis of the Glue Grant database J Trauma Acute Care Surg 2013 May74(5)1215-21 discussion 1221-2 doi 101097TA0b013e3182826e13

bull Neal MD Hoffman MK Cuschieri J Minei JP Maier RV Harbrecht BG Billiar TR Peitzman AB Moore EE Cohen MJ Sperry JL Crystalloid to packed red blood cell transfusion ratio in the massively transfused patient when a little goes a long way J Trauma Acute Care Surg 2012 Apr72(4)892-8 doi 101097TA0b013e31823d84a7

bull Niles SE McLaughlin DF Perkins JG et al Increased mortality associated with the early coagulopathy of trauma in combat casualties J Trauma 2008641459-63

bull Brohi K Singh J Heron M Coats T Acute traumatic coagulopathy J Trauma 2003541127-30

bull Cotton BA Gunter OL Isbell J et al Damage control hematology the impact of a trauma exsanguination protocol on survival and blood product utilization J Trauma 2008641177-82

bull Keneally RJ1 Parsons AM1 Willett PB1 Warm fresh whole blood and thoracic traumain iraq and afghanistan J Emerg Trauma Shock 2015 Jan-Mar8(1)21-5

bull Spinella PC1 Perkins JG Grathwohl KW Beekley AC Holcomb JB Warm fresh whole blood is independently associated with improved survival for patients with combat-related traumatic injuries J Trauma 2009 Apr66(4 Suppl)S69-76

bull Wafaisade A1 Lefering R2 Bouillon B3 Boumlhmer AB4 Gaumlszligler M5 Ruppert M5 TraumaRegister DGU Prehospital administration of tranexamic acid in trauma patients Crit Care 2016 May 1220(1)143

bull Ausset S1 Glassberg E Nadler R Sunde G Cap AP Hoffmann C Plang S Sailliol A Tranexamic acid as part of remote damage-control resuscitation in the prehospital setting A critical appraisal of the medical literature and available alternatives J Trauma Acute Care Surg 2015 Jun78(6 Suppl 1)S70-5

bull CRASH-2 trial collaborators Shakur H Roberts I Bautista R Caballero J Coats T Dewan Y El-Sayed H Gogichaishvili T Gupta S Herrera J Hunt B Iribhogbe P Izurieta M Khamis H Komolafe E Marrero MA Mejiacutea-Mantilla J Miranda J Morales C Olaomi O Olldashi F Perel P Peto R Ramana PV Ravi RR Yutthakasemsunt S Effects of tranexamic acid on death vascular occlusive events and blood transfusion in trauma patients with significant haemorrhage (CRASH-2) a randomised placebo-controlled trial Lancet 2010 Jul 3376(9734)23-32

bull Morrison JJ1 Dubose JJ Rasmussen TE Midwinter MJ Military Application of Tranexamic Acid in Trauma Emergency Resuscitation (MATTERs) Study Arch Surg 2012 Feb147(2)113-9

bull Morrison JJ1 Ross JD Dubose JJ Jansen JO Midwinter MJ Rasmussen TE Association of cryoprecipitate and tranexamic acid with improved survival following wartime injury findings from the MATTERs II Study JAMA Surg 2013 Mar148(3)218-25

TCCC Order of preference

for fluid resuscitation

bull Fresh whole blood

bull PRBCsFFPPlatelets in 111 ratio

bull PRBCsFFP in 11 ratio

bull PRBCs or FFP

bull Plasmalyte Normosol

bull Lactated Ringers

bull Not recommended Normal Saline

Tranexamic Acid

bull Antithrombolytic

bull ldquoHyperfibrinolysis of traumardquo

bull 1g over 10 min

bull Giving it faster can cause hypotension

bull May give up to 5g (studied up to 250mgkg)

bull Re-dose if hemorrhage is ongoing

Tranexamic Acid

bull CRASH-2 bull Given across a wide spectrum of trauma patients in 40 countries

bull ARR 15

bull Poorly controlled only half went to OR

bull MATTERs bull 17 vs 239 mortality

bull Benefit greatest in those getting MTP

bull MATTERs II bull TXA vs Cryo vs TXA+Cryo

bull 116 vs 236 mortality

bull Best benefit lt1h after injury

bull Some benefit lt3h after injury

bull Possible harm gt3h after injury

Tranexamic Acid

bull CRASH-2 TBI

bull Basically a wash

bull Cole Davenport Brohi TXA did not affect mortality in

overall or non-shock cohorts

bull MVA showed OR of MOF 027 and death 016

bull Valle Allen Higher mortality with TXA if needing gt2L

PRBCs

bull Given 97 min after ADMISSION and after transfusion

Factor VIIa

bull No studies showing mortality benefit

bull Studies showing decreased blood loss

bull $45000dose

bull May consider if still bleeding after TXA

Metabolic acidosis

bull Keep pH above 72

bull Administer THAM (Tromethamine solution) or sodium

bicarbonate to maintain pH

bull Weight in kg x base deficit x 11 = volume of THAM

solution to give (18g500mL)

bull Weight in kg x base deficit x 02 = volume of sodium

bicarb solution to give

Calcium

bull Calcium used up in clots

bull Calcium gobbled up by citrate in stored blood

bull Maintain ionized iCa gt 10 (run on ABG machine)

bull 1g Ca Gluconate for every 4 u FFP

Storage lesions

bull Stored blood is acidic

bull Calcium is chelated by preservatives

bull Platelets decline in function

Thromboelastography

(TEG)

bull Gives a better picture of coagulation status

bull Measures time to initiate clot

bull Speed of formation

bull Strength of clot

bull Fibrinolysis

bull Can help guide transfusion therapy

bull Better outcomes at gt10u PRBCs

bull Fewer units of blood

TEG

TEG Value Transfuse

TEG-ACT gt 140 FFP

R time gt 10 FFP

K time gt 3 Cryo

A angle Cry +- Platelets

MA lt 50 Platelets

LY30 gt3 TXA

REBOA

bull Resuscitative Endovascular Balloon Occlusion of the

Aorta

ER REBOA

Bottom Line

bull Keep them WARM

bull Little to no crystalloid

bull Hypotension is bad for brain injuries

bull Think about MT early

bull 111 ratio

bull Give TXA early

bull Calcium

bull Fix acidosis

bull Balogh Z McKinley BA Cocanour CS Kozar RA Valdivia A Sailors RM Moore FA Supra-normal trauma resuscitation causes more cases of abdominal compartment syndrome Arch Surg 138637-643 2003

bull Duchesne JC Heaney J Guidry C McSwain N Jr Meade P Cohen M Schreiber M Inaba K Skiada D Demetriades D Holcomb J Wade C Cotton B Diluting the benefits of hemostatic resuscitation A multi-institutional analysis J Trauma Acute Care Surg 2013 Jul75(1)76-82 doi 101097TA0b013e3182987df3

bull Guidry C Gleeson E Simms ER Stuke L Meade P McSwain NE Jr Duchesne JC Initial assessment on the impact of crystalloids versus colloids during damage control resuscitation J Surg Res 2013 Jun 15 pii S0022-4804(13)00568-4 doi 101016jjss201305086 [Epub ahead of print]

bull Perel P Roberts I Ker K Colloids versus crystalloids for fluid resuscitation in critically ill patients Cochrane Database Syst Rev 2013 Feb 282CD000567 doi 10100214651858CD000567pub6

bull Zarychanski R Abou-Setta AM Turgeon AF et al Association of Hydroxyethyl Starch Administration With Mortality and Acute Kidney Injury in Critically Ill Patients Requiring Volume Resuscitation A Systematic Review and Meta-analysis JAMA 2013309(7)678-688 doi101001jama2013430

bull Bulger EM May S Kerby JD Emerson S Stiell IG Schreiber MA Brasel KJ Tisherman SA Coimbra R Rizoli S Minei JP Hata JS Sopko G Evans DC Hoyt DB ROC investigators Out-of-hospital hypertonic resuscitation after traumatic hypovolemic shock a randomized placebo controlled trial Ann Surg 2011 Mar253(3)431-41 doi 101097SLA0b013e3181fcdb22

bull Vassar MJ Fischer RP OBrien PE Bachulis BL Chambers JA Hoyt DB Holcroft JW A multicenter trial for resuscitation of injured patients with 75 sodium chloride The effect of added dextran 70 The Multicenter Group for the Study of Hypertonic Saline in Trauma Patients Arch Surg 1993 Sep128(9)1003-11 discussion 1011-3

bull Cooper DJ Myles PS McDermott FT Murray LJ Laidlaw J Cooper G Tremayne AB Bernard SS Ponsford J HTS Study Investigators Prehospital hypertonic saline resuscitation of patients with hypotension and severe traumatic brain injury a randomized controlled trial JAMA 2004 Mar 17291(11)1350-7

bull Duke MD Guidry C Guice J Stuke L Marr AB Hunt JP Meade P McSwain NE Jr Duchesne JC Restrictive fluid resuscitation in combination with damage control resuscitation time for adaptation J Trauma Acute Care Surg 2012 Sep73(3)674-8 doi 101097TA0b013e318265ce1f

bull Pidcoke HF Aden JK Mora AG Borgman MA Spinella PC Dubick MA Blackbourne LH Cap AP Ten-year analysis of transfusion in Operation Iraqi Freedom and Operation Enduring Freedom increased plasma and platelet use correlates with improved survival J Trauma Acute Care Surg 2012 Dec73(6 Suppl 5)S445-52 doi 101097TA0b013e3182754796

bull Morrison CA Carrick MM Norman MA Scott BG Welsh FJ Tsai P Liscum KR Wall MJ Jr Mattox KL Hypotensive resuscitation strategy reduces transfusion requirements and severe postoperative coagulopathy in trauma patients with hemorrhagic shock preliminary results of a randomized controlled trial J Trauma 2011 Mar70(3)652-63 doi 101097TA0b013e31820e77ea

bull Ley EJ Clond MA Srour MK Barnajian M Mirocha J Margulies DR Salim A Emergency department crystalloid resuscitation of 15 L or more is associated with increased mortality in elderly and nonelderly trauma patients J Trauma 2011 Feb70(2)398-400 doi 101097TA0b013e318208f99b

bull Kasotakis G Sideris A Yang Y de Moya M Alam H King DR Tompkins R Velmahos G Inflammation and Host Response to Injury Investigators Aggressive early crystalloid resuscitation adversely affects outcomes in adult blunt trauma patients an analysis of the Glue Grant database J Trauma Acute Care Surg 2013 May74(5)1215-21 discussion 1221-2 doi 101097TA0b013e3182826e13

bull Neal MD Hoffman MK Cuschieri J Minei JP Maier RV Harbrecht BG Billiar TR Peitzman AB Moore EE Cohen MJ Sperry JL Crystalloid to packed red blood cell transfusion ratio in the massively transfused patient when a little goes a long way J Trauma Acute Care Surg 2012 Apr72(4)892-8 doi 101097TA0b013e31823d84a7

bull Niles SE McLaughlin DF Perkins JG et al Increased mortality associated with the early coagulopathy of trauma in combat casualties J Trauma 2008641459-63

bull Brohi K Singh J Heron M Coats T Acute traumatic coagulopathy J Trauma 2003541127-30

bull Cotton BA Gunter OL Isbell J et al Damage control hematology the impact of a trauma exsanguination protocol on survival and blood product utilization J Trauma 2008641177-82

bull Keneally RJ1 Parsons AM1 Willett PB1 Warm fresh whole blood and thoracic traumain iraq and afghanistan J Emerg Trauma Shock 2015 Jan-Mar8(1)21-5

bull Spinella PC1 Perkins JG Grathwohl KW Beekley AC Holcomb JB Warm fresh whole blood is independently associated with improved survival for patients with combat-related traumatic injuries J Trauma 2009 Apr66(4 Suppl)S69-76

bull Wafaisade A1 Lefering R2 Bouillon B3 Boumlhmer AB4 Gaumlszligler M5 Ruppert M5 TraumaRegister DGU Prehospital administration of tranexamic acid in trauma patients Crit Care 2016 May 1220(1)143

bull Ausset S1 Glassberg E Nadler R Sunde G Cap AP Hoffmann C Plang S Sailliol A Tranexamic acid as part of remote damage-control resuscitation in the prehospital setting A critical appraisal of the medical literature and available alternatives J Trauma Acute Care Surg 2015 Jun78(6 Suppl 1)S70-5

bull CRASH-2 trial collaborators Shakur H Roberts I Bautista R Caballero J Coats T Dewan Y El-Sayed H Gogichaishvili T Gupta S Herrera J Hunt B Iribhogbe P Izurieta M Khamis H Komolafe E Marrero MA Mejiacutea-Mantilla J Miranda J Morales C Olaomi O Olldashi F Perel P Peto R Ramana PV Ravi RR Yutthakasemsunt S Effects of tranexamic acid on death vascular occlusive events and blood transfusion in trauma patients with significant haemorrhage (CRASH-2) a randomised placebo-controlled trial Lancet 2010 Jul 3376(9734)23-32

bull Morrison JJ1 Dubose JJ Rasmussen TE Midwinter MJ Military Application of Tranexamic Acid in Trauma Emergency Resuscitation (MATTERs) Study Arch Surg 2012 Feb147(2)113-9

bull Morrison JJ1 Ross JD Dubose JJ Jansen JO Midwinter MJ Rasmussen TE Association of cryoprecipitate and tranexamic acid with improved survival following wartime injury findings from the MATTERs II Study JAMA Surg 2013 Mar148(3)218-25

Tranexamic Acid

bull Antithrombolytic

bull ldquoHyperfibrinolysis of traumardquo

bull 1g over 10 min

bull Giving it faster can cause hypotension

bull May give up to 5g (studied up to 250mgkg)

bull Re-dose if hemorrhage is ongoing

Tranexamic Acid

bull CRASH-2 bull Given across a wide spectrum of trauma patients in 40 countries

bull ARR 15

bull Poorly controlled only half went to OR

bull MATTERs bull 17 vs 239 mortality

bull Benefit greatest in those getting MTP

bull MATTERs II bull TXA vs Cryo vs TXA+Cryo

bull 116 vs 236 mortality

bull Best benefit lt1h after injury

bull Some benefit lt3h after injury

bull Possible harm gt3h after injury

Tranexamic Acid

bull CRASH-2 TBI

bull Basically a wash

bull Cole Davenport Brohi TXA did not affect mortality in

overall or non-shock cohorts

bull MVA showed OR of MOF 027 and death 016

bull Valle Allen Higher mortality with TXA if needing gt2L

PRBCs

bull Given 97 min after ADMISSION and after transfusion

Factor VIIa

bull No studies showing mortality benefit

bull Studies showing decreased blood loss

bull $45000dose

bull May consider if still bleeding after TXA

Metabolic acidosis

bull Keep pH above 72

bull Administer THAM (Tromethamine solution) or sodium

bicarbonate to maintain pH

bull Weight in kg x base deficit x 11 = volume of THAM

solution to give (18g500mL)

bull Weight in kg x base deficit x 02 = volume of sodium

bicarb solution to give

Calcium

bull Calcium used up in clots

bull Calcium gobbled up by citrate in stored blood

bull Maintain ionized iCa gt 10 (run on ABG machine)

bull 1g Ca Gluconate for every 4 u FFP

Storage lesions

bull Stored blood is acidic

bull Calcium is chelated by preservatives

bull Platelets decline in function

Thromboelastography

(TEG)

bull Gives a better picture of coagulation status

bull Measures time to initiate clot

bull Speed of formation

bull Strength of clot

bull Fibrinolysis

bull Can help guide transfusion therapy

bull Better outcomes at gt10u PRBCs

bull Fewer units of blood

TEG

TEG Value Transfuse

TEG-ACT gt 140 FFP

R time gt 10 FFP

K time gt 3 Cryo

A angle Cry +- Platelets

MA lt 50 Platelets

LY30 gt3 TXA

REBOA

bull Resuscitative Endovascular Balloon Occlusion of the

Aorta

ER REBOA

Bottom Line

bull Keep them WARM

bull Little to no crystalloid

bull Hypotension is bad for brain injuries

bull Think about MT early

bull 111 ratio

bull Give TXA early

bull Calcium

bull Fix acidosis

bull Balogh Z McKinley BA Cocanour CS Kozar RA Valdivia A Sailors RM Moore FA Supra-normal trauma resuscitation causes more cases of abdominal compartment syndrome Arch Surg 138637-643 2003

bull Duchesne JC Heaney J Guidry C McSwain N Jr Meade P Cohen M Schreiber M Inaba K Skiada D Demetriades D Holcomb J Wade C Cotton B Diluting the benefits of hemostatic resuscitation A multi-institutional analysis J Trauma Acute Care Surg 2013 Jul75(1)76-82 doi 101097TA0b013e3182987df3

bull Guidry C Gleeson E Simms ER Stuke L Meade P McSwain NE Jr Duchesne JC Initial assessment on the impact of crystalloids versus colloids during damage control resuscitation J Surg Res 2013 Jun 15 pii S0022-4804(13)00568-4 doi 101016jjss201305086 [Epub ahead of print]

bull Perel P Roberts I Ker K Colloids versus crystalloids for fluid resuscitation in critically ill patients Cochrane Database Syst Rev 2013 Feb 282CD000567 doi 10100214651858CD000567pub6

bull Zarychanski R Abou-Setta AM Turgeon AF et al Association of Hydroxyethyl Starch Administration With Mortality and Acute Kidney Injury in Critically Ill Patients Requiring Volume Resuscitation A Systematic Review and Meta-analysis JAMA 2013309(7)678-688 doi101001jama2013430

bull Bulger EM May S Kerby JD Emerson S Stiell IG Schreiber MA Brasel KJ Tisherman SA Coimbra R Rizoli S Minei JP Hata JS Sopko G Evans DC Hoyt DB ROC investigators Out-of-hospital hypertonic resuscitation after traumatic hypovolemic shock a randomized placebo controlled trial Ann Surg 2011 Mar253(3)431-41 doi 101097SLA0b013e3181fcdb22

bull Vassar MJ Fischer RP OBrien PE Bachulis BL Chambers JA Hoyt DB Holcroft JW A multicenter trial for resuscitation of injured patients with 75 sodium chloride The effect of added dextran 70 The Multicenter Group for the Study of Hypertonic Saline in Trauma Patients Arch Surg 1993 Sep128(9)1003-11 discussion 1011-3

bull Cooper DJ Myles PS McDermott FT Murray LJ Laidlaw J Cooper G Tremayne AB Bernard SS Ponsford J HTS Study Investigators Prehospital hypertonic saline resuscitation of patients with hypotension and severe traumatic brain injury a randomized controlled trial JAMA 2004 Mar 17291(11)1350-7

bull Duke MD Guidry C Guice J Stuke L Marr AB Hunt JP Meade P McSwain NE Jr Duchesne JC Restrictive fluid resuscitation in combination with damage control resuscitation time for adaptation J Trauma Acute Care Surg 2012 Sep73(3)674-8 doi 101097TA0b013e318265ce1f

bull Pidcoke HF Aden JK Mora AG Borgman MA Spinella PC Dubick MA Blackbourne LH Cap AP Ten-year analysis of transfusion in Operation Iraqi Freedom and Operation Enduring Freedom increased plasma and platelet use correlates with improved survival J Trauma Acute Care Surg 2012 Dec73(6 Suppl 5)S445-52 doi 101097TA0b013e3182754796

bull Morrison CA Carrick MM Norman MA Scott BG Welsh FJ Tsai P Liscum KR Wall MJ Jr Mattox KL Hypotensive resuscitation strategy reduces transfusion requirements and severe postoperative coagulopathy in trauma patients with hemorrhagic shock preliminary results of a randomized controlled trial J Trauma 2011 Mar70(3)652-63 doi 101097TA0b013e31820e77ea

bull Ley EJ Clond MA Srour MK Barnajian M Mirocha J Margulies DR Salim A Emergency department crystalloid resuscitation of 15 L or more is associated with increased mortality in elderly and nonelderly trauma patients J Trauma 2011 Feb70(2)398-400 doi 101097TA0b013e318208f99b

bull Kasotakis G Sideris A Yang Y de Moya M Alam H King DR Tompkins R Velmahos G Inflammation and Host Response to Injury Investigators Aggressive early crystalloid resuscitation adversely affects outcomes in adult blunt trauma patients an analysis of the Glue Grant database J Trauma Acute Care Surg 2013 May74(5)1215-21 discussion 1221-2 doi 101097TA0b013e3182826e13

bull Neal MD Hoffman MK Cuschieri J Minei JP Maier RV Harbrecht BG Billiar TR Peitzman AB Moore EE Cohen MJ Sperry JL Crystalloid to packed red blood cell transfusion ratio in the massively transfused patient when a little goes a long way J Trauma Acute Care Surg 2012 Apr72(4)892-8 doi 101097TA0b013e31823d84a7

bull Niles SE McLaughlin DF Perkins JG et al Increased mortality associated with the early coagulopathy of trauma in combat casualties J Trauma 2008641459-63

bull Brohi K Singh J Heron M Coats T Acute traumatic coagulopathy J Trauma 2003541127-30

bull Cotton BA Gunter OL Isbell J et al Damage control hematology the impact of a trauma exsanguination protocol on survival and blood product utilization J Trauma 2008641177-82

bull Keneally RJ1 Parsons AM1 Willett PB1 Warm fresh whole blood and thoracic traumain iraq and afghanistan J Emerg Trauma Shock 2015 Jan-Mar8(1)21-5

bull Spinella PC1 Perkins JG Grathwohl KW Beekley AC Holcomb JB Warm fresh whole blood is independently associated with improved survival for patients with combat-related traumatic injuries J Trauma 2009 Apr66(4 Suppl)S69-76

bull Wafaisade A1 Lefering R2 Bouillon B3 Boumlhmer AB4 Gaumlszligler M5 Ruppert M5 TraumaRegister DGU Prehospital administration of tranexamic acid in trauma patients Crit Care 2016 May 1220(1)143

bull Ausset S1 Glassberg E Nadler R Sunde G Cap AP Hoffmann C Plang S Sailliol A Tranexamic acid as part of remote damage-control resuscitation in the prehospital setting A critical appraisal of the medical literature and available alternatives J Trauma Acute Care Surg 2015 Jun78(6 Suppl 1)S70-5

bull CRASH-2 trial collaborators Shakur H Roberts I Bautista R Caballero J Coats T Dewan Y El-Sayed H Gogichaishvili T Gupta S Herrera J Hunt B Iribhogbe P Izurieta M Khamis H Komolafe E Marrero MA Mejiacutea-Mantilla J Miranda J Morales C Olaomi O Olldashi F Perel P Peto R Ramana PV Ravi RR Yutthakasemsunt S Effects of tranexamic acid on death vascular occlusive events and blood transfusion in trauma patients with significant haemorrhage (CRASH-2) a randomised placebo-controlled trial Lancet 2010 Jul 3376(9734)23-32

bull Morrison JJ1 Dubose JJ Rasmussen TE Midwinter MJ Military Application of Tranexamic Acid in Trauma Emergency Resuscitation (MATTERs) Study Arch Surg 2012 Feb147(2)113-9

bull Morrison JJ1 Ross JD Dubose JJ Jansen JO Midwinter MJ Rasmussen TE Association of cryoprecipitate and tranexamic acid with improved survival following wartime injury findings from the MATTERs II Study JAMA Surg 2013 Mar148(3)218-25

Tranexamic Acid

bull CRASH-2 bull Given across a wide spectrum of trauma patients in 40 countries

bull ARR 15

bull Poorly controlled only half went to OR

bull MATTERs bull 17 vs 239 mortality

bull Benefit greatest in those getting MTP

bull MATTERs II bull TXA vs Cryo vs TXA+Cryo

bull 116 vs 236 mortality

bull Best benefit lt1h after injury

bull Some benefit lt3h after injury

bull Possible harm gt3h after injury

Tranexamic Acid

bull CRASH-2 TBI

bull Basically a wash

bull Cole Davenport Brohi TXA did not affect mortality in

overall or non-shock cohorts

bull MVA showed OR of MOF 027 and death 016

bull Valle Allen Higher mortality with TXA if needing gt2L

PRBCs

bull Given 97 min after ADMISSION and after transfusion

Factor VIIa

bull No studies showing mortality benefit

bull Studies showing decreased blood loss

bull $45000dose

bull May consider if still bleeding after TXA

Metabolic acidosis

bull Keep pH above 72

bull Administer THAM (Tromethamine solution) or sodium

bicarbonate to maintain pH

bull Weight in kg x base deficit x 11 = volume of THAM

solution to give (18g500mL)

bull Weight in kg x base deficit x 02 = volume of sodium

bicarb solution to give

Calcium

bull Calcium used up in clots

bull Calcium gobbled up by citrate in stored blood

bull Maintain ionized iCa gt 10 (run on ABG machine)

bull 1g Ca Gluconate for every 4 u FFP

Storage lesions

bull Stored blood is acidic

bull Calcium is chelated by preservatives

bull Platelets decline in function

Thromboelastography

(TEG)

bull Gives a better picture of coagulation status

bull Measures time to initiate clot

bull Speed of formation

bull Strength of clot

bull Fibrinolysis

bull Can help guide transfusion therapy

bull Better outcomes at gt10u PRBCs

bull Fewer units of blood

TEG

TEG Value Transfuse

TEG-ACT gt 140 FFP

R time gt 10 FFP

K time gt 3 Cryo

A angle Cry +- Platelets

MA lt 50 Platelets

LY30 gt3 TXA

REBOA

bull Resuscitative Endovascular Balloon Occlusion of the

Aorta

ER REBOA

Bottom Line

bull Keep them WARM

bull Little to no crystalloid

bull Hypotension is bad for brain injuries

bull Think about MT early

bull 111 ratio

bull Give TXA early

bull Calcium

bull Fix acidosis

bull Balogh Z McKinley BA Cocanour CS Kozar RA Valdivia A Sailors RM Moore FA Supra-normal trauma resuscitation causes more cases of abdominal compartment syndrome Arch Surg 138637-643 2003

bull Duchesne JC Heaney J Guidry C McSwain N Jr Meade P Cohen M Schreiber M Inaba K Skiada D Demetriades D Holcomb J Wade C Cotton B Diluting the benefits of hemostatic resuscitation A multi-institutional analysis J Trauma Acute Care Surg 2013 Jul75(1)76-82 doi 101097TA0b013e3182987df3

bull Guidry C Gleeson E Simms ER Stuke L Meade P McSwain NE Jr Duchesne JC Initial assessment on the impact of crystalloids versus colloids during damage control resuscitation J Surg Res 2013 Jun 15 pii S0022-4804(13)00568-4 doi 101016jjss201305086 [Epub ahead of print]

bull Perel P Roberts I Ker K Colloids versus crystalloids for fluid resuscitation in critically ill patients Cochrane Database Syst Rev 2013 Feb 282CD000567 doi 10100214651858CD000567pub6

bull Zarychanski R Abou-Setta AM Turgeon AF et al Association of Hydroxyethyl Starch Administration With Mortality and Acute Kidney Injury in Critically Ill Patients Requiring Volume Resuscitation A Systematic Review and Meta-analysis JAMA 2013309(7)678-688 doi101001jama2013430

bull Bulger EM May S Kerby JD Emerson S Stiell IG Schreiber MA Brasel KJ Tisherman SA Coimbra R Rizoli S Minei JP Hata JS Sopko G Evans DC Hoyt DB ROC investigators Out-of-hospital hypertonic resuscitation after traumatic hypovolemic shock a randomized placebo controlled trial Ann Surg 2011 Mar253(3)431-41 doi 101097SLA0b013e3181fcdb22

bull Vassar MJ Fischer RP OBrien PE Bachulis BL Chambers JA Hoyt DB Holcroft JW A multicenter trial for resuscitation of injured patients with 75 sodium chloride The effect of added dextran 70 The Multicenter Group for the Study of Hypertonic Saline in Trauma Patients Arch Surg 1993 Sep128(9)1003-11 discussion 1011-3

bull Cooper DJ Myles PS McDermott FT Murray LJ Laidlaw J Cooper G Tremayne AB Bernard SS Ponsford J HTS Study Investigators Prehospital hypertonic saline resuscitation of patients with hypotension and severe traumatic brain injury a randomized controlled trial JAMA 2004 Mar 17291(11)1350-7

bull Duke MD Guidry C Guice J Stuke L Marr AB Hunt JP Meade P McSwain NE Jr Duchesne JC Restrictive fluid resuscitation in combination with damage control resuscitation time for adaptation J Trauma Acute Care Surg 2012 Sep73(3)674-8 doi 101097TA0b013e318265ce1f

bull Pidcoke HF Aden JK Mora AG Borgman MA Spinella PC Dubick MA Blackbourne LH Cap AP Ten-year analysis of transfusion in Operation Iraqi Freedom and Operation Enduring Freedom increased plasma and platelet use correlates with improved survival J Trauma Acute Care Surg 2012 Dec73(6 Suppl 5)S445-52 doi 101097TA0b013e3182754796

bull Morrison CA Carrick MM Norman MA Scott BG Welsh FJ Tsai P Liscum KR Wall MJ Jr Mattox KL Hypotensive resuscitation strategy reduces transfusion requirements and severe postoperative coagulopathy in trauma patients with hemorrhagic shock preliminary results of a randomized controlled trial J Trauma 2011 Mar70(3)652-63 doi 101097TA0b013e31820e77ea

bull Ley EJ Clond MA Srour MK Barnajian M Mirocha J Margulies DR Salim A Emergency department crystalloid resuscitation of 15 L or more is associated with increased mortality in elderly and nonelderly trauma patients J Trauma 2011 Feb70(2)398-400 doi 101097TA0b013e318208f99b

bull Kasotakis G Sideris A Yang Y de Moya M Alam H King DR Tompkins R Velmahos G Inflammation and Host Response to Injury Investigators Aggressive early crystalloid resuscitation adversely affects outcomes in adult blunt trauma patients an analysis of the Glue Grant database J Trauma Acute Care Surg 2013 May74(5)1215-21 discussion 1221-2 doi 101097TA0b013e3182826e13

bull Neal MD Hoffman MK Cuschieri J Minei JP Maier RV Harbrecht BG Billiar TR Peitzman AB Moore EE Cohen MJ Sperry JL Crystalloid to packed red blood cell transfusion ratio in the massively transfused patient when a little goes a long way J Trauma Acute Care Surg 2012 Apr72(4)892-8 doi 101097TA0b013e31823d84a7

bull Niles SE McLaughlin DF Perkins JG et al Increased mortality associated with the early coagulopathy of trauma in combat casualties J Trauma 2008641459-63

bull Brohi K Singh J Heron M Coats T Acute traumatic coagulopathy J Trauma 2003541127-30

bull Cotton BA Gunter OL Isbell J et al Damage control hematology the impact of a trauma exsanguination protocol on survival and blood product utilization J Trauma 2008641177-82

bull Keneally RJ1 Parsons AM1 Willett PB1 Warm fresh whole blood and thoracic traumain iraq and afghanistan J Emerg Trauma Shock 2015 Jan-Mar8(1)21-5

bull Spinella PC1 Perkins JG Grathwohl KW Beekley AC Holcomb JB Warm fresh whole blood is independently associated with improved survival for patients with combat-related traumatic injuries J Trauma 2009 Apr66(4 Suppl)S69-76

bull Wafaisade A1 Lefering R2 Bouillon B3 Boumlhmer AB4 Gaumlszligler M5 Ruppert M5 TraumaRegister DGU Prehospital administration of tranexamic acid in trauma patients Crit Care 2016 May 1220(1)143

bull Ausset S1 Glassberg E Nadler R Sunde G Cap AP Hoffmann C Plang S Sailliol A Tranexamic acid as part of remote damage-control resuscitation in the prehospital setting A critical appraisal of the medical literature and available alternatives J Trauma Acute Care Surg 2015 Jun78(6 Suppl 1)S70-5

bull CRASH-2 trial collaborators Shakur H Roberts I Bautista R Caballero J Coats T Dewan Y El-Sayed H Gogichaishvili T Gupta S Herrera J Hunt B Iribhogbe P Izurieta M Khamis H Komolafe E Marrero MA Mejiacutea-Mantilla J Miranda J Morales C Olaomi O Olldashi F Perel P Peto R Ramana PV Ravi RR Yutthakasemsunt S Effects of tranexamic acid on death vascular occlusive events and blood transfusion in trauma patients with significant haemorrhage (CRASH-2) a randomised placebo-controlled trial Lancet 2010 Jul 3376(9734)23-32

bull Morrison JJ1 Dubose JJ Rasmussen TE Midwinter MJ Military Application of Tranexamic Acid in Trauma Emergency Resuscitation (MATTERs) Study Arch Surg 2012 Feb147(2)113-9

bull Morrison JJ1 Ross JD Dubose JJ Jansen JO Midwinter MJ Rasmussen TE Association of cryoprecipitate and tranexamic acid with improved survival following wartime injury findings from the MATTERs II Study JAMA Surg 2013 Mar148(3)218-25

Tranexamic Acid

bull CRASH-2 TBI

bull Basically a wash

bull Cole Davenport Brohi TXA did not affect mortality in

overall or non-shock cohorts

bull MVA showed OR of MOF 027 and death 016

bull Valle Allen Higher mortality with TXA if needing gt2L

PRBCs

bull Given 97 min after ADMISSION and after transfusion

Factor VIIa

bull No studies showing mortality benefit

bull Studies showing decreased blood loss

bull $45000dose

bull May consider if still bleeding after TXA

Metabolic acidosis

bull Keep pH above 72

bull Administer THAM (Tromethamine solution) or sodium

bicarbonate to maintain pH

bull Weight in kg x base deficit x 11 = volume of THAM

solution to give (18g500mL)

bull Weight in kg x base deficit x 02 = volume of sodium

bicarb solution to give

Calcium

bull Calcium used up in clots

bull Calcium gobbled up by citrate in stored blood

bull Maintain ionized iCa gt 10 (run on ABG machine)

bull 1g Ca Gluconate for every 4 u FFP

Storage lesions

bull Stored blood is acidic

bull Calcium is chelated by preservatives

bull Platelets decline in function

Thromboelastography

(TEG)

bull Gives a better picture of coagulation status

bull Measures time to initiate clot

bull Speed of formation

bull Strength of clot

bull Fibrinolysis

bull Can help guide transfusion therapy

bull Better outcomes at gt10u PRBCs

bull Fewer units of blood

TEG

TEG Value Transfuse

TEG-ACT gt 140 FFP

R time gt 10 FFP

K time gt 3 Cryo

A angle Cry +- Platelets

MA lt 50 Platelets

LY30 gt3 TXA

REBOA

bull Resuscitative Endovascular Balloon Occlusion of the

Aorta

ER REBOA

Bottom Line

bull Keep them WARM

bull Little to no crystalloid

bull Hypotension is bad for brain injuries

bull Think about MT early

bull 111 ratio

bull Give TXA early

bull Calcium

bull Fix acidosis

bull Balogh Z McKinley BA Cocanour CS Kozar RA Valdivia A Sailors RM Moore FA Supra-normal trauma resuscitation causes more cases of abdominal compartment syndrome Arch Surg 138637-643 2003

bull Duchesne JC Heaney J Guidry C McSwain N Jr Meade P Cohen M Schreiber M Inaba K Skiada D Demetriades D Holcomb J Wade C Cotton B Diluting the benefits of hemostatic resuscitation A multi-institutional analysis J Trauma Acute Care Surg 2013 Jul75(1)76-82 doi 101097TA0b013e3182987df3

bull Guidry C Gleeson E Simms ER Stuke L Meade P McSwain NE Jr Duchesne JC Initial assessment on the impact of crystalloids versus colloids during damage control resuscitation J Surg Res 2013 Jun 15 pii S0022-4804(13)00568-4 doi 101016jjss201305086 [Epub ahead of print]

bull Perel P Roberts I Ker K Colloids versus crystalloids for fluid resuscitation in critically ill patients Cochrane Database Syst Rev 2013 Feb 282CD000567 doi 10100214651858CD000567pub6

bull Zarychanski R Abou-Setta AM Turgeon AF et al Association of Hydroxyethyl Starch Administration With Mortality and Acute Kidney Injury in Critically Ill Patients Requiring Volume Resuscitation A Systematic Review and Meta-analysis JAMA 2013309(7)678-688 doi101001jama2013430

bull Bulger EM May S Kerby JD Emerson S Stiell IG Schreiber MA Brasel KJ Tisherman SA Coimbra R Rizoli S Minei JP Hata JS Sopko G Evans DC Hoyt DB ROC investigators Out-of-hospital hypertonic resuscitation after traumatic hypovolemic shock a randomized placebo controlled trial Ann Surg 2011 Mar253(3)431-41 doi 101097SLA0b013e3181fcdb22

bull Vassar MJ Fischer RP OBrien PE Bachulis BL Chambers JA Hoyt DB Holcroft JW A multicenter trial for resuscitation of injured patients with 75 sodium chloride The effect of added dextran 70 The Multicenter Group for the Study of Hypertonic Saline in Trauma Patients Arch Surg 1993 Sep128(9)1003-11 discussion 1011-3

bull Cooper DJ Myles PS McDermott FT Murray LJ Laidlaw J Cooper G Tremayne AB Bernard SS Ponsford J HTS Study Investigators Prehospital hypertonic saline resuscitation of patients with hypotension and severe traumatic brain injury a randomized controlled trial JAMA 2004 Mar 17291(11)1350-7

bull Duke MD Guidry C Guice J Stuke L Marr AB Hunt JP Meade P McSwain NE Jr Duchesne JC Restrictive fluid resuscitation in combination with damage control resuscitation time for adaptation J Trauma Acute Care Surg 2012 Sep73(3)674-8 doi 101097TA0b013e318265ce1f

bull Pidcoke HF Aden JK Mora AG Borgman MA Spinella PC Dubick MA Blackbourne LH Cap AP Ten-year analysis of transfusion in Operation Iraqi Freedom and Operation Enduring Freedom increased plasma and platelet use correlates with improved survival J Trauma Acute Care Surg 2012 Dec73(6 Suppl 5)S445-52 doi 101097TA0b013e3182754796

bull Morrison CA Carrick MM Norman MA Scott BG Welsh FJ Tsai P Liscum KR Wall MJ Jr Mattox KL Hypotensive resuscitation strategy reduces transfusion requirements and severe postoperative coagulopathy in trauma patients with hemorrhagic shock preliminary results of a randomized controlled trial J Trauma 2011 Mar70(3)652-63 doi 101097TA0b013e31820e77ea

bull Ley EJ Clond MA Srour MK Barnajian M Mirocha J Margulies DR Salim A Emergency department crystalloid resuscitation of 15 L or more is associated with increased mortality in elderly and nonelderly trauma patients J Trauma 2011 Feb70(2)398-400 doi 101097TA0b013e318208f99b

bull Kasotakis G Sideris A Yang Y de Moya M Alam H King DR Tompkins R Velmahos G Inflammation and Host Response to Injury Investigators Aggressive early crystalloid resuscitation adversely affects outcomes in adult blunt trauma patients an analysis of the Glue Grant database J Trauma Acute Care Surg 2013 May74(5)1215-21 discussion 1221-2 doi 101097TA0b013e3182826e13

bull Neal MD Hoffman MK Cuschieri J Minei JP Maier RV Harbrecht BG Billiar TR Peitzman AB Moore EE Cohen MJ Sperry JL Crystalloid to packed red blood cell transfusion ratio in the massively transfused patient when a little goes a long way J Trauma Acute Care Surg 2012 Apr72(4)892-8 doi 101097TA0b013e31823d84a7

bull Niles SE McLaughlin DF Perkins JG et al Increased mortality associated with the early coagulopathy of trauma in combat casualties J Trauma 2008641459-63

bull Brohi K Singh J Heron M Coats T Acute traumatic coagulopathy J Trauma 2003541127-30

bull Cotton BA Gunter OL Isbell J et al Damage control hematology the impact of a trauma exsanguination protocol on survival and blood product utilization J Trauma 2008641177-82

bull Keneally RJ1 Parsons AM1 Willett PB1 Warm fresh whole blood and thoracic traumain iraq and afghanistan J Emerg Trauma Shock 2015 Jan-Mar8(1)21-5

bull Spinella PC1 Perkins JG Grathwohl KW Beekley AC Holcomb JB Warm fresh whole blood is independently associated with improved survival for patients with combat-related traumatic injuries J Trauma 2009 Apr66(4 Suppl)S69-76

bull Wafaisade A1 Lefering R2 Bouillon B3 Boumlhmer AB4 Gaumlszligler M5 Ruppert M5 TraumaRegister DGU Prehospital administration of tranexamic acid in trauma patients Crit Care 2016 May 1220(1)143

bull Ausset S1 Glassberg E Nadler R Sunde G Cap AP Hoffmann C Plang S Sailliol A Tranexamic acid as part of remote damage-control resuscitation in the prehospital setting A critical appraisal of the medical literature and available alternatives J Trauma Acute Care Surg 2015 Jun78(6 Suppl 1)S70-5

bull CRASH-2 trial collaborators Shakur H Roberts I Bautista R Caballero J Coats T Dewan Y El-Sayed H Gogichaishvili T Gupta S Herrera J Hunt B Iribhogbe P Izurieta M Khamis H Komolafe E Marrero MA Mejiacutea-Mantilla J Miranda J Morales C Olaomi O Olldashi F Perel P Peto R Ramana PV Ravi RR Yutthakasemsunt S Effects of tranexamic acid on death vascular occlusive events and blood transfusion in trauma patients with significant haemorrhage (CRASH-2) a randomised placebo-controlled trial Lancet 2010 Jul 3376(9734)23-32

bull Morrison JJ1 Dubose JJ Rasmussen TE Midwinter MJ Military Application of Tranexamic Acid in Trauma Emergency Resuscitation (MATTERs) Study Arch Surg 2012 Feb147(2)113-9

bull Morrison JJ1 Ross JD Dubose JJ Jansen JO Midwinter MJ Rasmussen TE Association of cryoprecipitate and tranexamic acid with improved survival following wartime injury findings from the MATTERs II Study JAMA Surg 2013 Mar148(3)218-25

Factor VIIa

bull No studies showing mortality benefit

bull Studies showing decreased blood loss

bull $45000dose

bull May consider if still bleeding after TXA

Metabolic acidosis

bull Keep pH above 72

bull Administer THAM (Tromethamine solution) or sodium

bicarbonate to maintain pH

bull Weight in kg x base deficit x 11 = volume of THAM

solution to give (18g500mL)

bull Weight in kg x base deficit x 02 = volume of sodium

bicarb solution to give

Calcium

bull Calcium used up in clots

bull Calcium gobbled up by citrate in stored blood

bull Maintain ionized iCa gt 10 (run on ABG machine)

bull 1g Ca Gluconate for every 4 u FFP

Storage lesions

bull Stored blood is acidic

bull Calcium is chelated by preservatives

bull Platelets decline in function

Thromboelastography

(TEG)

bull Gives a better picture of coagulation status

bull Measures time to initiate clot

bull Speed of formation

bull Strength of clot

bull Fibrinolysis

bull Can help guide transfusion therapy

bull Better outcomes at gt10u PRBCs

bull Fewer units of blood

TEG

TEG Value Transfuse

TEG-ACT gt 140 FFP

R time gt 10 FFP

K time gt 3 Cryo

A angle Cry +- Platelets

MA lt 50 Platelets

LY30 gt3 TXA

REBOA

bull Resuscitative Endovascular Balloon Occlusion of the

Aorta

ER REBOA

Bottom Line

bull Keep them WARM

bull Little to no crystalloid

bull Hypotension is bad for brain injuries

bull Think about MT early

bull 111 ratio

bull Give TXA early

bull Calcium

bull Fix acidosis

bull Balogh Z McKinley BA Cocanour CS Kozar RA Valdivia A Sailors RM Moore FA Supra-normal trauma resuscitation causes more cases of abdominal compartment syndrome Arch Surg 138637-643 2003

bull Duchesne JC Heaney J Guidry C McSwain N Jr Meade P Cohen M Schreiber M Inaba K Skiada D Demetriades D Holcomb J Wade C Cotton B Diluting the benefits of hemostatic resuscitation A multi-institutional analysis J Trauma Acute Care Surg 2013 Jul75(1)76-82 doi 101097TA0b013e3182987df3

bull Guidry C Gleeson E Simms ER Stuke L Meade P McSwain NE Jr Duchesne JC Initial assessment on the impact of crystalloids versus colloids during damage control resuscitation J Surg Res 2013 Jun 15 pii S0022-4804(13)00568-4 doi 101016jjss201305086 [Epub ahead of print]

bull Perel P Roberts I Ker K Colloids versus crystalloids for fluid resuscitation in critically ill patients Cochrane Database Syst Rev 2013 Feb 282CD000567 doi 10100214651858CD000567pub6

bull Zarychanski R Abou-Setta AM Turgeon AF et al Association of Hydroxyethyl Starch Administration With Mortality and Acute Kidney Injury in Critically Ill Patients Requiring Volume Resuscitation A Systematic Review and Meta-analysis JAMA 2013309(7)678-688 doi101001jama2013430

bull Bulger EM May S Kerby JD Emerson S Stiell IG Schreiber MA Brasel KJ Tisherman SA Coimbra R Rizoli S Minei JP Hata JS Sopko G Evans DC Hoyt DB ROC investigators Out-of-hospital hypertonic resuscitation after traumatic hypovolemic shock a randomized placebo controlled trial Ann Surg 2011 Mar253(3)431-41 doi 101097SLA0b013e3181fcdb22

bull Vassar MJ Fischer RP OBrien PE Bachulis BL Chambers JA Hoyt DB Holcroft JW A multicenter trial for resuscitation of injured patients with 75 sodium chloride The effect of added dextran 70 The Multicenter Group for the Study of Hypertonic Saline in Trauma Patients Arch Surg 1993 Sep128(9)1003-11 discussion 1011-3

bull Cooper DJ Myles PS McDermott FT Murray LJ Laidlaw J Cooper G Tremayne AB Bernard SS Ponsford J HTS Study Investigators Prehospital hypertonic saline resuscitation of patients with hypotension and severe traumatic brain injury a randomized controlled trial JAMA 2004 Mar 17291(11)1350-7

bull Duke MD Guidry C Guice J Stuke L Marr AB Hunt JP Meade P McSwain NE Jr Duchesne JC Restrictive fluid resuscitation in combination with damage control resuscitation time for adaptation J Trauma Acute Care Surg 2012 Sep73(3)674-8 doi 101097TA0b013e318265ce1f

bull Pidcoke HF Aden JK Mora AG Borgman MA Spinella PC Dubick MA Blackbourne LH Cap AP Ten-year analysis of transfusion in Operation Iraqi Freedom and Operation Enduring Freedom increased plasma and platelet use correlates with improved survival J Trauma Acute Care Surg 2012 Dec73(6 Suppl 5)S445-52 doi 101097TA0b013e3182754796

bull Morrison CA Carrick MM Norman MA Scott BG Welsh FJ Tsai P Liscum KR Wall MJ Jr Mattox KL Hypotensive resuscitation strategy reduces transfusion requirements and severe postoperative coagulopathy in trauma patients with hemorrhagic shock preliminary results of a randomized controlled trial J Trauma 2011 Mar70(3)652-63 doi 101097TA0b013e31820e77ea

bull Ley EJ Clond MA Srour MK Barnajian M Mirocha J Margulies DR Salim A Emergency department crystalloid resuscitation of 15 L or more is associated with increased mortality in elderly and nonelderly trauma patients J Trauma 2011 Feb70(2)398-400 doi 101097TA0b013e318208f99b

bull Kasotakis G Sideris A Yang Y de Moya M Alam H King DR Tompkins R Velmahos G Inflammation and Host Response to Injury Investigators Aggressive early crystalloid resuscitation adversely affects outcomes in adult blunt trauma patients an analysis of the Glue Grant database J Trauma Acute Care Surg 2013 May74(5)1215-21 discussion 1221-2 doi 101097TA0b013e3182826e13

bull Neal MD Hoffman MK Cuschieri J Minei JP Maier RV Harbrecht BG Billiar TR Peitzman AB Moore EE Cohen MJ Sperry JL Crystalloid to packed red blood cell transfusion ratio in the massively transfused patient when a little goes a long way J Trauma Acute Care Surg 2012 Apr72(4)892-8 doi 101097TA0b013e31823d84a7

bull Niles SE McLaughlin DF Perkins JG et al Increased mortality associated with the early coagulopathy of trauma in combat casualties J Trauma 2008641459-63

bull Brohi K Singh J Heron M Coats T Acute traumatic coagulopathy J Trauma 2003541127-30

bull Cotton BA Gunter OL Isbell J et al Damage control hematology the impact of a trauma exsanguination protocol on survival and blood product utilization J Trauma 2008641177-82

bull Keneally RJ1 Parsons AM1 Willett PB1 Warm fresh whole blood and thoracic traumain iraq and afghanistan J Emerg Trauma Shock 2015 Jan-Mar8(1)21-5

bull Spinella PC1 Perkins JG Grathwohl KW Beekley AC Holcomb JB Warm fresh whole blood is independently associated with improved survival for patients with combat-related traumatic injuries J Trauma 2009 Apr66(4 Suppl)S69-76

bull Wafaisade A1 Lefering R2 Bouillon B3 Boumlhmer AB4 Gaumlszligler M5 Ruppert M5 TraumaRegister DGU Prehospital administration of tranexamic acid in trauma patients Crit Care 2016 May 1220(1)143

bull Ausset S1 Glassberg E Nadler R Sunde G Cap AP Hoffmann C Plang S Sailliol A Tranexamic acid as part of remote damage-control resuscitation in the prehospital setting A critical appraisal of the medical literature and available alternatives J Trauma Acute Care Surg 2015 Jun78(6 Suppl 1)S70-5

bull CRASH-2 trial collaborators Shakur H Roberts I Bautista R Caballero J Coats T Dewan Y El-Sayed H Gogichaishvili T Gupta S Herrera J Hunt B Iribhogbe P Izurieta M Khamis H Komolafe E Marrero MA Mejiacutea-Mantilla J Miranda J Morales C Olaomi O Olldashi F Perel P Peto R Ramana PV Ravi RR Yutthakasemsunt S Effects of tranexamic acid on death vascular occlusive events and blood transfusion in trauma patients with significant haemorrhage (CRASH-2) a randomised placebo-controlled trial Lancet 2010 Jul 3376(9734)23-32

bull Morrison JJ1 Dubose JJ Rasmussen TE Midwinter MJ Military Application of Tranexamic Acid in Trauma Emergency Resuscitation (MATTERs) Study Arch Surg 2012 Feb147(2)113-9

bull Morrison JJ1 Ross JD Dubose JJ Jansen JO Midwinter MJ Rasmussen TE Association of cryoprecipitate and tranexamic acid with improved survival following wartime injury findings from the MATTERs II Study JAMA Surg 2013 Mar148(3)218-25

Metabolic acidosis

bull Keep pH above 72

bull Administer THAM (Tromethamine solution) or sodium

bicarbonate to maintain pH

bull Weight in kg x base deficit x 11 = volume of THAM

solution to give (18g500mL)

bull Weight in kg x base deficit x 02 = volume of sodium

bicarb solution to give

Calcium

bull Calcium used up in clots

bull Calcium gobbled up by citrate in stored blood

bull Maintain ionized iCa gt 10 (run on ABG machine)

bull 1g Ca Gluconate for every 4 u FFP

Storage lesions

bull Stored blood is acidic

bull Calcium is chelated by preservatives

bull Platelets decline in function

Thromboelastography

(TEG)

bull Gives a better picture of coagulation status

bull Measures time to initiate clot

bull Speed of formation

bull Strength of clot

bull Fibrinolysis

bull Can help guide transfusion therapy

bull Better outcomes at gt10u PRBCs

bull Fewer units of blood

TEG

TEG Value Transfuse

TEG-ACT gt 140 FFP

R time gt 10 FFP

K time gt 3 Cryo

A angle Cry +- Platelets

MA lt 50 Platelets

LY30 gt3 TXA

REBOA

bull Resuscitative Endovascular Balloon Occlusion of the

Aorta

ER REBOA

Bottom Line

bull Keep them WARM

bull Little to no crystalloid

bull Hypotension is bad for brain injuries

bull Think about MT early

bull 111 ratio

bull Give TXA early

bull Calcium

bull Fix acidosis

bull Balogh Z McKinley BA Cocanour CS Kozar RA Valdivia A Sailors RM Moore FA Supra-normal trauma resuscitation causes more cases of abdominal compartment syndrome Arch Surg 138637-643 2003

bull Duchesne JC Heaney J Guidry C McSwain N Jr Meade P Cohen M Schreiber M Inaba K Skiada D Demetriades D Holcomb J Wade C Cotton B Diluting the benefits of hemostatic resuscitation A multi-institutional analysis J Trauma Acute Care Surg 2013 Jul75(1)76-82 doi 101097TA0b013e3182987df3

bull Guidry C Gleeson E Simms ER Stuke L Meade P McSwain NE Jr Duchesne JC Initial assessment on the impact of crystalloids versus colloids during damage control resuscitation J Surg Res 2013 Jun 15 pii S0022-4804(13)00568-4 doi 101016jjss201305086 [Epub ahead of print]

bull Perel P Roberts I Ker K Colloids versus crystalloids for fluid resuscitation in critically ill patients Cochrane Database Syst Rev 2013 Feb 282CD000567 doi 10100214651858CD000567pub6

bull Zarychanski R Abou-Setta AM Turgeon AF et al Association of Hydroxyethyl Starch Administration With Mortality and Acute Kidney Injury in Critically Ill Patients Requiring Volume Resuscitation A Systematic Review and Meta-analysis JAMA 2013309(7)678-688 doi101001jama2013430

bull Bulger EM May S Kerby JD Emerson S Stiell IG Schreiber MA Brasel KJ Tisherman SA Coimbra R Rizoli S Minei JP Hata JS Sopko G Evans DC Hoyt DB ROC investigators Out-of-hospital hypertonic resuscitation after traumatic hypovolemic shock a randomized placebo controlled trial Ann Surg 2011 Mar253(3)431-41 doi 101097SLA0b013e3181fcdb22

bull Vassar MJ Fischer RP OBrien PE Bachulis BL Chambers JA Hoyt DB Holcroft JW A multicenter trial for resuscitation of injured patients with 75 sodium chloride The effect of added dextran 70 The Multicenter Group for the Study of Hypertonic Saline in Trauma Patients Arch Surg 1993 Sep128(9)1003-11 discussion 1011-3

bull Cooper DJ Myles PS McDermott FT Murray LJ Laidlaw J Cooper G Tremayne AB Bernard SS Ponsford J HTS Study Investigators Prehospital hypertonic saline resuscitation of patients with hypotension and severe traumatic brain injury a randomized controlled trial JAMA 2004 Mar 17291(11)1350-7

bull Duke MD Guidry C Guice J Stuke L Marr AB Hunt JP Meade P McSwain NE Jr Duchesne JC Restrictive fluid resuscitation in combination with damage control resuscitation time for adaptation J Trauma Acute Care Surg 2012 Sep73(3)674-8 doi 101097TA0b013e318265ce1f

bull Pidcoke HF Aden JK Mora AG Borgman MA Spinella PC Dubick MA Blackbourne LH Cap AP Ten-year analysis of transfusion in Operation Iraqi Freedom and Operation Enduring Freedom increased plasma and platelet use correlates with improved survival J Trauma Acute Care Surg 2012 Dec73(6 Suppl 5)S445-52 doi 101097TA0b013e3182754796

bull Morrison CA Carrick MM Norman MA Scott BG Welsh FJ Tsai P Liscum KR Wall MJ Jr Mattox KL Hypotensive resuscitation strategy reduces transfusion requirements and severe postoperative coagulopathy in trauma patients with hemorrhagic shock preliminary results of a randomized controlled trial J Trauma 2011 Mar70(3)652-63 doi 101097TA0b013e31820e77ea

bull Ley EJ Clond MA Srour MK Barnajian M Mirocha J Margulies DR Salim A Emergency department crystalloid resuscitation of 15 L or more is associated with increased mortality in elderly and nonelderly trauma patients J Trauma 2011 Feb70(2)398-400 doi 101097TA0b013e318208f99b

bull Kasotakis G Sideris A Yang Y de Moya M Alam H King DR Tompkins R Velmahos G Inflammation and Host Response to Injury Investigators Aggressive early crystalloid resuscitation adversely affects outcomes in adult blunt trauma patients an analysis of the Glue Grant database J Trauma Acute Care Surg 2013 May74(5)1215-21 discussion 1221-2 doi 101097TA0b013e3182826e13

bull Neal MD Hoffman MK Cuschieri J Minei JP Maier RV Harbrecht BG Billiar TR Peitzman AB Moore EE Cohen MJ Sperry JL Crystalloid to packed red blood cell transfusion ratio in the massively transfused patient when a little goes a long way J Trauma Acute Care Surg 2012 Apr72(4)892-8 doi 101097TA0b013e31823d84a7

bull Niles SE McLaughlin DF Perkins JG et al Increased mortality associated with the early coagulopathy of trauma in combat casualties J Trauma 2008641459-63

bull Brohi K Singh J Heron M Coats T Acute traumatic coagulopathy J Trauma 2003541127-30

bull Cotton BA Gunter OL Isbell J et al Damage control hematology the impact of a trauma exsanguination protocol on survival and blood product utilization J Trauma 2008641177-82

bull Keneally RJ1 Parsons AM1 Willett PB1 Warm fresh whole blood and thoracic traumain iraq and afghanistan J Emerg Trauma Shock 2015 Jan-Mar8(1)21-5

bull Spinella PC1 Perkins JG Grathwohl KW Beekley AC Holcomb JB Warm fresh whole blood is independently associated with improved survival for patients with combat-related traumatic injuries J Trauma 2009 Apr66(4 Suppl)S69-76

bull Wafaisade A1 Lefering R2 Bouillon B3 Boumlhmer AB4 Gaumlszligler M5 Ruppert M5 TraumaRegister DGU Prehospital administration of tranexamic acid in trauma patients Crit Care 2016 May 1220(1)143

bull Ausset S1 Glassberg E Nadler R Sunde G Cap AP Hoffmann C Plang S Sailliol A Tranexamic acid as part of remote damage-control resuscitation in the prehospital setting A critical appraisal of the medical literature and available alternatives J Trauma Acute Care Surg 2015 Jun78(6 Suppl 1)S70-5

bull CRASH-2 trial collaborators Shakur H Roberts I Bautista R Caballero J Coats T Dewan Y El-Sayed H Gogichaishvili T Gupta S Herrera J Hunt B Iribhogbe P Izurieta M Khamis H Komolafe E Marrero MA Mejiacutea-Mantilla J Miranda J Morales C Olaomi O Olldashi F Perel P Peto R Ramana PV Ravi RR Yutthakasemsunt S Effects of tranexamic acid on death vascular occlusive events and blood transfusion in trauma patients with significant haemorrhage (CRASH-2) a randomised placebo-controlled trial Lancet 2010 Jul 3376(9734)23-32

bull Morrison JJ1 Dubose JJ Rasmussen TE Midwinter MJ Military Application of Tranexamic Acid in Trauma Emergency Resuscitation (MATTERs) Study Arch Surg 2012 Feb147(2)113-9

bull Morrison JJ1 Ross JD Dubose JJ Jansen JO Midwinter MJ Rasmussen TE Association of cryoprecipitate and tranexamic acid with improved survival following wartime injury findings from the MATTERs II Study JAMA Surg 2013 Mar148(3)218-25

Calcium

bull Calcium used up in clots

bull Calcium gobbled up by citrate in stored blood

bull Maintain ionized iCa gt 10 (run on ABG machine)

bull 1g Ca Gluconate for every 4 u FFP

Storage lesions

bull Stored blood is acidic

bull Calcium is chelated by preservatives

bull Platelets decline in function

Thromboelastography

(TEG)

bull Gives a better picture of coagulation status

bull Measures time to initiate clot

bull Speed of formation

bull Strength of clot

bull Fibrinolysis

bull Can help guide transfusion therapy

bull Better outcomes at gt10u PRBCs

bull Fewer units of blood

TEG

TEG Value Transfuse

TEG-ACT gt 140 FFP

R time gt 10 FFP

K time gt 3 Cryo

A angle Cry +- Platelets

MA lt 50 Platelets

LY30 gt3 TXA

REBOA

bull Resuscitative Endovascular Balloon Occlusion of the

Aorta

ER REBOA

Bottom Line

bull Keep them WARM

bull Little to no crystalloid

bull Hypotension is bad for brain injuries

bull Think about MT early

bull 111 ratio

bull Give TXA early

bull Calcium

bull Fix acidosis

bull Balogh Z McKinley BA Cocanour CS Kozar RA Valdivia A Sailors RM Moore FA Supra-normal trauma resuscitation causes more cases of abdominal compartment syndrome Arch Surg 138637-643 2003

bull Duchesne JC Heaney J Guidry C McSwain N Jr Meade P Cohen M Schreiber M Inaba K Skiada D Demetriades D Holcomb J Wade C Cotton B Diluting the benefits of hemostatic resuscitation A multi-institutional analysis J Trauma Acute Care Surg 2013 Jul75(1)76-82 doi 101097TA0b013e3182987df3

bull Guidry C Gleeson E Simms ER Stuke L Meade P McSwain NE Jr Duchesne JC Initial assessment on the impact of crystalloids versus colloids during damage control resuscitation J Surg Res 2013 Jun 15 pii S0022-4804(13)00568-4 doi 101016jjss201305086 [Epub ahead of print]

bull Perel P Roberts I Ker K Colloids versus crystalloids for fluid resuscitation in critically ill patients Cochrane Database Syst Rev 2013 Feb 282CD000567 doi 10100214651858CD000567pub6

bull Zarychanski R Abou-Setta AM Turgeon AF et al Association of Hydroxyethyl Starch Administration With Mortality and Acute Kidney Injury in Critically Ill Patients Requiring Volume Resuscitation A Systematic Review and Meta-analysis JAMA 2013309(7)678-688 doi101001jama2013430

bull Bulger EM May S Kerby JD Emerson S Stiell IG Schreiber MA Brasel KJ Tisherman SA Coimbra R Rizoli S Minei JP Hata JS Sopko G Evans DC Hoyt DB ROC investigators Out-of-hospital hypertonic resuscitation after traumatic hypovolemic shock a randomized placebo controlled trial Ann Surg 2011 Mar253(3)431-41 doi 101097SLA0b013e3181fcdb22

bull Vassar MJ Fischer RP OBrien PE Bachulis BL Chambers JA Hoyt DB Holcroft JW A multicenter trial for resuscitation of injured patients with 75 sodium chloride The effect of added dextran 70 The Multicenter Group for the Study of Hypertonic Saline in Trauma Patients Arch Surg 1993 Sep128(9)1003-11 discussion 1011-3

bull Cooper DJ Myles PS McDermott FT Murray LJ Laidlaw J Cooper G Tremayne AB Bernard SS Ponsford J HTS Study Investigators Prehospital hypertonic saline resuscitation of patients with hypotension and severe traumatic brain injury a randomized controlled trial JAMA 2004 Mar 17291(11)1350-7

bull Duke MD Guidry C Guice J Stuke L Marr AB Hunt JP Meade P McSwain NE Jr Duchesne JC Restrictive fluid resuscitation in combination with damage control resuscitation time for adaptation J Trauma Acute Care Surg 2012 Sep73(3)674-8 doi 101097TA0b013e318265ce1f

bull Pidcoke HF Aden JK Mora AG Borgman MA Spinella PC Dubick MA Blackbourne LH Cap AP Ten-year analysis of transfusion in Operation Iraqi Freedom and Operation Enduring Freedom increased plasma and platelet use correlates with improved survival J Trauma Acute Care Surg 2012 Dec73(6 Suppl 5)S445-52 doi 101097TA0b013e3182754796

bull Morrison CA Carrick MM Norman MA Scott BG Welsh FJ Tsai P Liscum KR Wall MJ Jr Mattox KL Hypotensive resuscitation strategy reduces transfusion requirements and severe postoperative coagulopathy in trauma patients with hemorrhagic shock preliminary results of a randomized controlled trial J Trauma 2011 Mar70(3)652-63 doi 101097TA0b013e31820e77ea

bull Ley EJ Clond MA Srour MK Barnajian M Mirocha J Margulies DR Salim A Emergency department crystalloid resuscitation of 15 L or more is associated with increased mortality in elderly and nonelderly trauma patients J Trauma 2011 Feb70(2)398-400 doi 101097TA0b013e318208f99b

bull Kasotakis G Sideris A Yang Y de Moya M Alam H King DR Tompkins R Velmahos G Inflammation and Host Response to Injury Investigators Aggressive early crystalloid resuscitation adversely affects outcomes in adult blunt trauma patients an analysis of the Glue Grant database J Trauma Acute Care Surg 2013 May74(5)1215-21 discussion 1221-2 doi 101097TA0b013e3182826e13

bull Neal MD Hoffman MK Cuschieri J Minei JP Maier RV Harbrecht BG Billiar TR Peitzman AB Moore EE Cohen MJ Sperry JL Crystalloid to packed red blood cell transfusion ratio in the massively transfused patient when a little goes a long way J Trauma Acute Care Surg 2012 Apr72(4)892-8 doi 101097TA0b013e31823d84a7

bull Niles SE McLaughlin DF Perkins JG et al Increased mortality associated with the early coagulopathy of trauma in combat casualties J Trauma 2008641459-63

bull Brohi K Singh J Heron M Coats T Acute traumatic coagulopathy J Trauma 2003541127-30

bull Cotton BA Gunter OL Isbell J et al Damage control hematology the impact of a trauma exsanguination protocol on survival and blood product utilization J Trauma 2008641177-82

bull Keneally RJ1 Parsons AM1 Willett PB1 Warm fresh whole blood and thoracic traumain iraq and afghanistan J Emerg Trauma Shock 2015 Jan-Mar8(1)21-5

bull Spinella PC1 Perkins JG Grathwohl KW Beekley AC Holcomb JB Warm fresh whole blood is independently associated with improved survival for patients with combat-related traumatic injuries J Trauma 2009 Apr66(4 Suppl)S69-76

bull Wafaisade A1 Lefering R2 Bouillon B3 Boumlhmer AB4 Gaumlszligler M5 Ruppert M5 TraumaRegister DGU Prehospital administration of tranexamic acid in trauma patients Crit Care 2016 May 1220(1)143

bull Ausset S1 Glassberg E Nadler R Sunde G Cap AP Hoffmann C Plang S Sailliol A Tranexamic acid as part of remote damage-control resuscitation in the prehospital setting A critical appraisal of the medical literature and available alternatives J Trauma Acute Care Surg 2015 Jun78(6 Suppl 1)S70-5

bull CRASH-2 trial collaborators Shakur H Roberts I Bautista R Caballero J Coats T Dewan Y El-Sayed H Gogichaishvili T Gupta S Herrera J Hunt B Iribhogbe P Izurieta M Khamis H Komolafe E Marrero MA Mejiacutea-Mantilla J Miranda J Morales C Olaomi O Olldashi F Perel P Peto R Ramana PV Ravi RR Yutthakasemsunt S Effects of tranexamic acid on death vascular occlusive events and blood transfusion in trauma patients with significant haemorrhage (CRASH-2) a randomised placebo-controlled trial Lancet 2010 Jul 3376(9734)23-32

bull Morrison JJ1 Dubose JJ Rasmussen TE Midwinter MJ Military Application of Tranexamic Acid in Trauma Emergency Resuscitation (MATTERs) Study Arch Surg 2012 Feb147(2)113-9

bull Morrison JJ1 Ross JD Dubose JJ Jansen JO Midwinter MJ Rasmussen TE Association of cryoprecipitate and tranexamic acid with improved survival following wartime injury findings from the MATTERs II Study JAMA Surg 2013 Mar148(3)218-25

Storage lesions

bull Stored blood is acidic

bull Calcium is chelated by preservatives

bull Platelets decline in function

Thromboelastography

(TEG)

bull Gives a better picture of coagulation status

bull Measures time to initiate clot

bull Speed of formation

bull Strength of clot

bull Fibrinolysis

bull Can help guide transfusion therapy

bull Better outcomes at gt10u PRBCs

bull Fewer units of blood

TEG

TEG Value Transfuse

TEG-ACT gt 140 FFP

R time gt 10 FFP

K time gt 3 Cryo

A angle Cry +- Platelets

MA lt 50 Platelets

LY30 gt3 TXA

REBOA

bull Resuscitative Endovascular Balloon Occlusion of the

Aorta

ER REBOA

Bottom Line

bull Keep them WARM

bull Little to no crystalloid

bull Hypotension is bad for brain injuries

bull Think about MT early

bull 111 ratio

bull Give TXA early

bull Calcium

bull Fix acidosis

bull Balogh Z McKinley BA Cocanour CS Kozar RA Valdivia A Sailors RM Moore FA Supra-normal trauma resuscitation causes more cases of abdominal compartment syndrome Arch Surg 138637-643 2003

bull Duchesne JC Heaney J Guidry C McSwain N Jr Meade P Cohen M Schreiber M Inaba K Skiada D Demetriades D Holcomb J Wade C Cotton B Diluting the benefits of hemostatic resuscitation A multi-institutional analysis J Trauma Acute Care Surg 2013 Jul75(1)76-82 doi 101097TA0b013e3182987df3

bull Guidry C Gleeson E Simms ER Stuke L Meade P McSwain NE Jr Duchesne JC Initial assessment on the impact of crystalloids versus colloids during damage control resuscitation J Surg Res 2013 Jun 15 pii S0022-4804(13)00568-4 doi 101016jjss201305086 [Epub ahead of print]

bull Perel P Roberts I Ker K Colloids versus crystalloids for fluid resuscitation in critically ill patients Cochrane Database Syst Rev 2013 Feb 282CD000567 doi 10100214651858CD000567pub6

bull Zarychanski R Abou-Setta AM Turgeon AF et al Association of Hydroxyethyl Starch Administration With Mortality and Acute Kidney Injury in Critically Ill Patients Requiring Volume Resuscitation A Systematic Review and Meta-analysis JAMA 2013309(7)678-688 doi101001jama2013430

bull Bulger EM May S Kerby JD Emerson S Stiell IG Schreiber MA Brasel KJ Tisherman SA Coimbra R Rizoli S Minei JP Hata JS Sopko G Evans DC Hoyt DB ROC investigators Out-of-hospital hypertonic resuscitation after traumatic hypovolemic shock a randomized placebo controlled trial Ann Surg 2011 Mar253(3)431-41 doi 101097SLA0b013e3181fcdb22

bull Vassar MJ Fischer RP OBrien PE Bachulis BL Chambers JA Hoyt DB Holcroft JW A multicenter trial for resuscitation of injured patients with 75 sodium chloride The effect of added dextran 70 The Multicenter Group for the Study of Hypertonic Saline in Trauma Patients Arch Surg 1993 Sep128(9)1003-11 discussion 1011-3

bull Cooper DJ Myles PS McDermott FT Murray LJ Laidlaw J Cooper G Tremayne AB Bernard SS Ponsford J HTS Study Investigators Prehospital hypertonic saline resuscitation of patients with hypotension and severe traumatic brain injury a randomized controlled trial JAMA 2004 Mar 17291(11)1350-7

bull Duke MD Guidry C Guice J Stuke L Marr AB Hunt JP Meade P McSwain NE Jr Duchesne JC Restrictive fluid resuscitation in combination with damage control resuscitation time for adaptation J Trauma Acute Care Surg 2012 Sep73(3)674-8 doi 101097TA0b013e318265ce1f

bull Pidcoke HF Aden JK Mora AG Borgman MA Spinella PC Dubick MA Blackbourne LH Cap AP Ten-year analysis of transfusion in Operation Iraqi Freedom and Operation Enduring Freedom increased plasma and platelet use correlates with improved survival J Trauma Acute Care Surg 2012 Dec73(6 Suppl 5)S445-52 doi 101097TA0b013e3182754796

bull Morrison CA Carrick MM Norman MA Scott BG Welsh FJ Tsai P Liscum KR Wall MJ Jr Mattox KL Hypotensive resuscitation strategy reduces transfusion requirements and severe postoperative coagulopathy in trauma patients with hemorrhagic shock preliminary results of a randomized controlled trial J Trauma 2011 Mar70(3)652-63 doi 101097TA0b013e31820e77ea

bull Ley EJ Clond MA Srour MK Barnajian M Mirocha J Margulies DR Salim A Emergency department crystalloid resuscitation of 15 L or more is associated with increased mortality in elderly and nonelderly trauma patients J Trauma 2011 Feb70(2)398-400 doi 101097TA0b013e318208f99b

bull Kasotakis G Sideris A Yang Y de Moya M Alam H King DR Tompkins R Velmahos G Inflammation and Host Response to Injury Investigators Aggressive early crystalloid resuscitation adversely affects outcomes in adult blunt trauma patients an analysis of the Glue Grant database J Trauma Acute Care Surg 2013 May74(5)1215-21 discussion 1221-2 doi 101097TA0b013e3182826e13

bull Neal MD Hoffman MK Cuschieri J Minei JP Maier RV Harbrecht BG Billiar TR Peitzman AB Moore EE Cohen MJ Sperry JL Crystalloid to packed red blood cell transfusion ratio in the massively transfused patient when a little goes a long way J Trauma Acute Care Surg 2012 Apr72(4)892-8 doi 101097TA0b013e31823d84a7

bull Niles SE McLaughlin DF Perkins JG et al Increased mortality associated with the early coagulopathy of trauma in combat casualties J Trauma 2008641459-63

bull Brohi K Singh J Heron M Coats T Acute traumatic coagulopathy J Trauma 2003541127-30

bull Cotton BA Gunter OL Isbell J et al Damage control hematology the impact of a trauma exsanguination protocol on survival and blood product utilization J Trauma 2008641177-82

bull Keneally RJ1 Parsons AM1 Willett PB1 Warm fresh whole blood and thoracic traumain iraq and afghanistan J Emerg Trauma Shock 2015 Jan-Mar8(1)21-5

bull Spinella PC1 Perkins JG Grathwohl KW Beekley AC Holcomb JB Warm fresh whole blood is independently associated with improved survival for patients with combat-related traumatic injuries J Trauma 2009 Apr66(4 Suppl)S69-76

bull Wafaisade A1 Lefering R2 Bouillon B3 Boumlhmer AB4 Gaumlszligler M5 Ruppert M5 TraumaRegister DGU Prehospital administration of tranexamic acid in trauma patients Crit Care 2016 May 1220(1)143

bull Ausset S1 Glassberg E Nadler R Sunde G Cap AP Hoffmann C Plang S Sailliol A Tranexamic acid as part of remote damage-control resuscitation in the prehospital setting A critical appraisal of the medical literature and available alternatives J Trauma Acute Care Surg 2015 Jun78(6 Suppl 1)S70-5

bull CRASH-2 trial collaborators Shakur H Roberts I Bautista R Caballero J Coats T Dewan Y El-Sayed H Gogichaishvili T Gupta S Herrera J Hunt B Iribhogbe P Izurieta M Khamis H Komolafe E Marrero MA Mejiacutea-Mantilla J Miranda J Morales C Olaomi O Olldashi F Perel P Peto R Ramana PV Ravi RR Yutthakasemsunt S Effects of tranexamic acid on death vascular occlusive events and blood transfusion in trauma patients with significant haemorrhage (CRASH-2) a randomised placebo-controlled trial Lancet 2010 Jul 3376(9734)23-32

bull Morrison JJ1 Dubose JJ Rasmussen TE Midwinter MJ Military Application of Tranexamic Acid in Trauma Emergency Resuscitation (MATTERs) Study Arch Surg 2012 Feb147(2)113-9

bull Morrison JJ1 Ross JD Dubose JJ Jansen JO Midwinter MJ Rasmussen TE Association of cryoprecipitate and tranexamic acid with improved survival following wartime injury findings from the MATTERs II Study JAMA Surg 2013 Mar148(3)218-25

Thromboelastography

(TEG)

bull Gives a better picture of coagulation status

bull Measures time to initiate clot

bull Speed of formation

bull Strength of clot

bull Fibrinolysis

bull Can help guide transfusion therapy

bull Better outcomes at gt10u PRBCs

bull Fewer units of blood

TEG

TEG Value Transfuse

TEG-ACT gt 140 FFP

R time gt 10 FFP

K time gt 3 Cryo

A angle Cry +- Platelets

MA lt 50 Platelets

LY30 gt3 TXA

REBOA

bull Resuscitative Endovascular Balloon Occlusion of the

Aorta

ER REBOA

Bottom Line

bull Keep them WARM

bull Little to no crystalloid

bull Hypotension is bad for brain injuries

bull Think about MT early

bull 111 ratio

bull Give TXA early

bull Calcium

bull Fix acidosis

bull Balogh Z McKinley BA Cocanour CS Kozar RA Valdivia A Sailors RM Moore FA Supra-normal trauma resuscitation causes more cases of abdominal compartment syndrome Arch Surg 138637-643 2003

bull Duchesne JC Heaney J Guidry C McSwain N Jr Meade P Cohen M Schreiber M Inaba K Skiada D Demetriades D Holcomb J Wade C Cotton B Diluting the benefits of hemostatic resuscitation A multi-institutional analysis J Trauma Acute Care Surg 2013 Jul75(1)76-82 doi 101097TA0b013e3182987df3

bull Guidry C Gleeson E Simms ER Stuke L Meade P McSwain NE Jr Duchesne JC Initial assessment on the impact of crystalloids versus colloids during damage control resuscitation J Surg Res 2013 Jun 15 pii S0022-4804(13)00568-4 doi 101016jjss201305086 [Epub ahead of print]

bull Perel P Roberts I Ker K Colloids versus crystalloids for fluid resuscitation in critically ill patients Cochrane Database Syst Rev 2013 Feb 282CD000567 doi 10100214651858CD000567pub6

bull Zarychanski R Abou-Setta AM Turgeon AF et al Association of Hydroxyethyl Starch Administration With Mortality and Acute Kidney Injury in Critically Ill Patients Requiring Volume Resuscitation A Systematic Review and Meta-analysis JAMA 2013309(7)678-688 doi101001jama2013430

bull Bulger EM May S Kerby JD Emerson S Stiell IG Schreiber MA Brasel KJ Tisherman SA Coimbra R Rizoli S Minei JP Hata JS Sopko G Evans DC Hoyt DB ROC investigators Out-of-hospital hypertonic resuscitation after traumatic hypovolemic shock a randomized placebo controlled trial Ann Surg 2011 Mar253(3)431-41 doi 101097SLA0b013e3181fcdb22

bull Vassar MJ Fischer RP OBrien PE Bachulis BL Chambers JA Hoyt DB Holcroft JW A multicenter trial for resuscitation of injured patients with 75 sodium chloride The effect of added dextran 70 The Multicenter Group for the Study of Hypertonic Saline in Trauma Patients Arch Surg 1993 Sep128(9)1003-11 discussion 1011-3

bull Cooper DJ Myles PS McDermott FT Murray LJ Laidlaw J Cooper G Tremayne AB Bernard SS Ponsford J HTS Study Investigators Prehospital hypertonic saline resuscitation of patients with hypotension and severe traumatic brain injury a randomized controlled trial JAMA 2004 Mar 17291(11)1350-7

bull Duke MD Guidry C Guice J Stuke L Marr AB Hunt JP Meade P McSwain NE Jr Duchesne JC Restrictive fluid resuscitation in combination with damage control resuscitation time for adaptation J Trauma Acute Care Surg 2012 Sep73(3)674-8 doi 101097TA0b013e318265ce1f

bull Pidcoke HF Aden JK Mora AG Borgman MA Spinella PC Dubick MA Blackbourne LH Cap AP Ten-year analysis of transfusion in Operation Iraqi Freedom and Operation Enduring Freedom increased plasma and platelet use correlates with improved survival J Trauma Acute Care Surg 2012 Dec73(6 Suppl 5)S445-52 doi 101097TA0b013e3182754796

bull Morrison CA Carrick MM Norman MA Scott BG Welsh FJ Tsai P Liscum KR Wall MJ Jr Mattox KL Hypotensive resuscitation strategy reduces transfusion requirements and severe postoperative coagulopathy in trauma patients with hemorrhagic shock preliminary results of a randomized controlled trial J Trauma 2011 Mar70(3)652-63 doi 101097TA0b013e31820e77ea

bull Ley EJ Clond MA Srour MK Barnajian M Mirocha J Margulies DR Salim A Emergency department crystalloid resuscitation of 15 L or more is associated with increased mortality in elderly and nonelderly trauma patients J Trauma 2011 Feb70(2)398-400 doi 101097TA0b013e318208f99b

bull Kasotakis G Sideris A Yang Y de Moya M Alam H King DR Tompkins R Velmahos G Inflammation and Host Response to Injury Investigators Aggressive early crystalloid resuscitation adversely affects outcomes in adult blunt trauma patients an analysis of the Glue Grant database J Trauma Acute Care Surg 2013 May74(5)1215-21 discussion 1221-2 doi 101097TA0b013e3182826e13

bull Neal MD Hoffman MK Cuschieri J Minei JP Maier RV Harbrecht BG Billiar TR Peitzman AB Moore EE Cohen MJ Sperry JL Crystalloid to packed red blood cell transfusion ratio in the massively transfused patient when a little goes a long way J Trauma Acute Care Surg 2012 Apr72(4)892-8 doi 101097TA0b013e31823d84a7

bull Niles SE McLaughlin DF Perkins JG et al Increased mortality associated with the early coagulopathy of trauma in combat casualties J Trauma 2008641459-63

bull Brohi K Singh J Heron M Coats T Acute traumatic coagulopathy J Trauma 2003541127-30

bull Cotton BA Gunter OL Isbell J et al Damage control hematology the impact of a trauma exsanguination protocol on survival and blood product utilization J Trauma 2008641177-82

bull Keneally RJ1 Parsons AM1 Willett PB1 Warm fresh whole blood and thoracic traumain iraq and afghanistan J Emerg Trauma Shock 2015 Jan-Mar8(1)21-5

bull Spinella PC1 Perkins JG Grathwohl KW Beekley AC Holcomb JB Warm fresh whole blood is independently associated with improved survival for patients with combat-related traumatic injuries J Trauma 2009 Apr66(4 Suppl)S69-76

bull Wafaisade A1 Lefering R2 Bouillon B3 Boumlhmer AB4 Gaumlszligler M5 Ruppert M5 TraumaRegister DGU Prehospital administration of tranexamic acid in trauma patients Crit Care 2016 May 1220(1)143

bull Ausset S1 Glassberg E Nadler R Sunde G Cap AP Hoffmann C Plang S Sailliol A Tranexamic acid as part of remote damage-control resuscitation in the prehospital setting A critical appraisal of the medical literature and available alternatives J Trauma Acute Care Surg 2015 Jun78(6 Suppl 1)S70-5

bull CRASH-2 trial collaborators Shakur H Roberts I Bautista R Caballero J Coats T Dewan Y El-Sayed H Gogichaishvili T Gupta S Herrera J Hunt B Iribhogbe P Izurieta M Khamis H Komolafe E Marrero MA Mejiacutea-Mantilla J Miranda J Morales C Olaomi O Olldashi F Perel P Peto R Ramana PV Ravi RR Yutthakasemsunt S Effects of tranexamic acid on death vascular occlusive events and blood transfusion in trauma patients with significant haemorrhage (CRASH-2) a randomised placebo-controlled trial Lancet 2010 Jul 3376(9734)23-32

bull Morrison JJ1 Dubose JJ Rasmussen TE Midwinter MJ Military Application of Tranexamic Acid in Trauma Emergency Resuscitation (MATTERs) Study Arch Surg 2012 Feb147(2)113-9

bull Morrison JJ1 Ross JD Dubose JJ Jansen JO Midwinter MJ Rasmussen TE Association of cryoprecipitate and tranexamic acid with improved survival following wartime injury findings from the MATTERs II Study JAMA Surg 2013 Mar148(3)218-25

TEG

TEG Value Transfuse

TEG-ACT gt 140 FFP

R time gt 10 FFP

K time gt 3 Cryo

A angle Cry +- Platelets

MA lt 50 Platelets

LY30 gt3 TXA

REBOA

bull Resuscitative Endovascular Balloon Occlusion of the

Aorta

ER REBOA

Bottom Line

bull Keep them WARM

bull Little to no crystalloid

bull Hypotension is bad for brain injuries

bull Think about MT early

bull 111 ratio

bull Give TXA early

bull Calcium

bull Fix acidosis

bull Balogh Z McKinley BA Cocanour CS Kozar RA Valdivia A Sailors RM Moore FA Supra-normal trauma resuscitation causes more cases of abdominal compartment syndrome Arch Surg 138637-643 2003

bull Duchesne JC Heaney J Guidry C McSwain N Jr Meade P Cohen M Schreiber M Inaba K Skiada D Demetriades D Holcomb J Wade C Cotton B Diluting the benefits of hemostatic resuscitation A multi-institutional analysis J Trauma Acute Care Surg 2013 Jul75(1)76-82 doi 101097TA0b013e3182987df3

bull Guidry C Gleeson E Simms ER Stuke L Meade P McSwain NE Jr Duchesne JC Initial assessment on the impact of crystalloids versus colloids during damage control resuscitation J Surg Res 2013 Jun 15 pii S0022-4804(13)00568-4 doi 101016jjss201305086 [Epub ahead of print]

bull Perel P Roberts I Ker K Colloids versus crystalloids for fluid resuscitation in critically ill patients Cochrane Database Syst Rev 2013 Feb 282CD000567 doi 10100214651858CD000567pub6

bull Zarychanski R Abou-Setta AM Turgeon AF et al Association of Hydroxyethyl Starch Administration With Mortality and Acute Kidney Injury in Critically Ill Patients Requiring Volume Resuscitation A Systematic Review and Meta-analysis JAMA 2013309(7)678-688 doi101001jama2013430

bull Bulger EM May S Kerby JD Emerson S Stiell IG Schreiber MA Brasel KJ Tisherman SA Coimbra R Rizoli S Minei JP Hata JS Sopko G Evans DC Hoyt DB ROC investigators Out-of-hospital hypertonic resuscitation after traumatic hypovolemic shock a randomized placebo controlled trial Ann Surg 2011 Mar253(3)431-41 doi 101097SLA0b013e3181fcdb22

bull Vassar MJ Fischer RP OBrien PE Bachulis BL Chambers JA Hoyt DB Holcroft JW A multicenter trial for resuscitation of injured patients with 75 sodium chloride The effect of added dextran 70 The Multicenter Group for the Study of Hypertonic Saline in Trauma Patients Arch Surg 1993 Sep128(9)1003-11 discussion 1011-3

bull Cooper DJ Myles PS McDermott FT Murray LJ Laidlaw J Cooper G Tremayne AB Bernard SS Ponsford J HTS Study Investigators Prehospital hypertonic saline resuscitation of patients with hypotension and severe traumatic brain injury a randomized controlled trial JAMA 2004 Mar 17291(11)1350-7

bull Duke MD Guidry C Guice J Stuke L Marr AB Hunt JP Meade P McSwain NE Jr Duchesne JC Restrictive fluid resuscitation in combination with damage control resuscitation time for adaptation J Trauma Acute Care Surg 2012 Sep73(3)674-8 doi 101097TA0b013e318265ce1f

bull Pidcoke HF Aden JK Mora AG Borgman MA Spinella PC Dubick MA Blackbourne LH Cap AP Ten-year analysis of transfusion in Operation Iraqi Freedom and Operation Enduring Freedom increased plasma and platelet use correlates with improved survival J Trauma Acute Care Surg 2012 Dec73(6 Suppl 5)S445-52 doi 101097TA0b013e3182754796

bull Morrison CA Carrick MM Norman MA Scott BG Welsh FJ Tsai P Liscum KR Wall MJ Jr Mattox KL Hypotensive resuscitation strategy reduces transfusion requirements and severe postoperative coagulopathy in trauma patients with hemorrhagic shock preliminary results of a randomized controlled trial J Trauma 2011 Mar70(3)652-63 doi 101097TA0b013e31820e77ea

bull Ley EJ Clond MA Srour MK Barnajian M Mirocha J Margulies DR Salim A Emergency department crystalloid resuscitation of 15 L or more is associated with increased mortality in elderly and nonelderly trauma patients J Trauma 2011 Feb70(2)398-400 doi 101097TA0b013e318208f99b

bull Kasotakis G Sideris A Yang Y de Moya M Alam H King DR Tompkins R Velmahos G Inflammation and Host Response to Injury Investigators Aggressive early crystalloid resuscitation adversely affects outcomes in adult blunt trauma patients an analysis of the Glue Grant database J Trauma Acute Care Surg 2013 May74(5)1215-21 discussion 1221-2 doi 101097TA0b013e3182826e13

bull Neal MD Hoffman MK Cuschieri J Minei JP Maier RV Harbrecht BG Billiar TR Peitzman AB Moore EE Cohen MJ Sperry JL Crystalloid to packed red blood cell transfusion ratio in the massively transfused patient when a little goes a long way J Trauma Acute Care Surg 2012 Apr72(4)892-8 doi 101097TA0b013e31823d84a7

bull Niles SE McLaughlin DF Perkins JG et al Increased mortality associated with the early coagulopathy of trauma in combat casualties J Trauma 2008641459-63

bull Brohi K Singh J Heron M Coats T Acute traumatic coagulopathy J Trauma 2003541127-30

bull Cotton BA Gunter OL Isbell J et al Damage control hematology the impact of a trauma exsanguination protocol on survival and blood product utilization J Trauma 2008641177-82

bull Keneally RJ1 Parsons AM1 Willett PB1 Warm fresh whole blood and thoracic traumain iraq and afghanistan J Emerg Trauma Shock 2015 Jan-Mar8(1)21-5

bull Spinella PC1 Perkins JG Grathwohl KW Beekley AC Holcomb JB Warm fresh whole blood is independently associated with improved survival for patients with combat-related traumatic injuries J Trauma 2009 Apr66(4 Suppl)S69-76

bull Wafaisade A1 Lefering R2 Bouillon B3 Boumlhmer AB4 Gaumlszligler M5 Ruppert M5 TraumaRegister DGU Prehospital administration of tranexamic acid in trauma patients Crit Care 2016 May 1220(1)143

bull Ausset S1 Glassberg E Nadler R Sunde G Cap AP Hoffmann C Plang S Sailliol A Tranexamic acid as part of remote damage-control resuscitation in the prehospital setting A critical appraisal of the medical literature and available alternatives J Trauma Acute Care Surg 2015 Jun78(6 Suppl 1)S70-5

bull CRASH-2 trial collaborators Shakur H Roberts I Bautista R Caballero J Coats T Dewan Y El-Sayed H Gogichaishvili T Gupta S Herrera J Hunt B Iribhogbe P Izurieta M Khamis H Komolafe E Marrero MA Mejiacutea-Mantilla J Miranda J Morales C Olaomi O Olldashi F Perel P Peto R Ramana PV Ravi RR Yutthakasemsunt S Effects of tranexamic acid on death vascular occlusive events and blood transfusion in trauma patients with significant haemorrhage (CRASH-2) a randomised placebo-controlled trial Lancet 2010 Jul 3376(9734)23-32

bull Morrison JJ1 Dubose JJ Rasmussen TE Midwinter MJ Military Application of Tranexamic Acid in Trauma Emergency Resuscitation (MATTERs) Study Arch Surg 2012 Feb147(2)113-9

bull Morrison JJ1 Ross JD Dubose JJ Jansen JO Midwinter MJ Rasmussen TE Association of cryoprecipitate and tranexamic acid with improved survival following wartime injury findings from the MATTERs II Study JAMA Surg 2013 Mar148(3)218-25

REBOA

bull Resuscitative Endovascular Balloon Occlusion of the

Aorta

ER REBOA

Bottom Line

bull Keep them WARM

bull Little to no crystalloid

bull Hypotension is bad for brain injuries

bull Think about MT early

bull 111 ratio

bull Give TXA early

bull Calcium

bull Fix acidosis

bull Balogh Z McKinley BA Cocanour CS Kozar RA Valdivia A Sailors RM Moore FA Supra-normal trauma resuscitation causes more cases of abdominal compartment syndrome Arch Surg 138637-643 2003

bull Duchesne JC Heaney J Guidry C McSwain N Jr Meade P Cohen M Schreiber M Inaba K Skiada D Demetriades D Holcomb J Wade C Cotton B Diluting the benefits of hemostatic resuscitation A multi-institutional analysis J Trauma Acute Care Surg 2013 Jul75(1)76-82 doi 101097TA0b013e3182987df3

bull Guidry C Gleeson E Simms ER Stuke L Meade P McSwain NE Jr Duchesne JC Initial assessment on the impact of crystalloids versus colloids during damage control resuscitation J Surg Res 2013 Jun 15 pii S0022-4804(13)00568-4 doi 101016jjss201305086 [Epub ahead of print]

bull Perel P Roberts I Ker K Colloids versus crystalloids for fluid resuscitation in critically ill patients Cochrane Database Syst Rev 2013 Feb 282CD000567 doi 10100214651858CD000567pub6

bull Zarychanski R Abou-Setta AM Turgeon AF et al Association of Hydroxyethyl Starch Administration With Mortality and Acute Kidney Injury in Critically Ill Patients Requiring Volume Resuscitation A Systematic Review and Meta-analysis JAMA 2013309(7)678-688 doi101001jama2013430

bull Bulger EM May S Kerby JD Emerson S Stiell IG Schreiber MA Brasel KJ Tisherman SA Coimbra R Rizoli S Minei JP Hata JS Sopko G Evans DC Hoyt DB ROC investigators Out-of-hospital hypertonic resuscitation after traumatic hypovolemic shock a randomized placebo controlled trial Ann Surg 2011 Mar253(3)431-41 doi 101097SLA0b013e3181fcdb22

bull Vassar MJ Fischer RP OBrien PE Bachulis BL Chambers JA Hoyt DB Holcroft JW A multicenter trial for resuscitation of injured patients with 75 sodium chloride The effect of added dextran 70 The Multicenter Group for the Study of Hypertonic Saline in Trauma Patients Arch Surg 1993 Sep128(9)1003-11 discussion 1011-3

bull Cooper DJ Myles PS McDermott FT Murray LJ Laidlaw J Cooper G Tremayne AB Bernard SS Ponsford J HTS Study Investigators Prehospital hypertonic saline resuscitation of patients with hypotension and severe traumatic brain injury a randomized controlled trial JAMA 2004 Mar 17291(11)1350-7

bull Duke MD Guidry C Guice J Stuke L Marr AB Hunt JP Meade P McSwain NE Jr Duchesne JC Restrictive fluid resuscitation in combination with damage control resuscitation time for adaptation J Trauma Acute Care Surg 2012 Sep73(3)674-8 doi 101097TA0b013e318265ce1f

bull Pidcoke HF Aden JK Mora AG Borgman MA Spinella PC Dubick MA Blackbourne LH Cap AP Ten-year analysis of transfusion in Operation Iraqi Freedom and Operation Enduring Freedom increased plasma and platelet use correlates with improved survival J Trauma Acute Care Surg 2012 Dec73(6 Suppl 5)S445-52 doi 101097TA0b013e3182754796

bull Morrison CA Carrick MM Norman MA Scott BG Welsh FJ Tsai P Liscum KR Wall MJ Jr Mattox KL Hypotensive resuscitation strategy reduces transfusion requirements and severe postoperative coagulopathy in trauma patients with hemorrhagic shock preliminary results of a randomized controlled trial J Trauma 2011 Mar70(3)652-63 doi 101097TA0b013e31820e77ea

bull Ley EJ Clond MA Srour MK Barnajian M Mirocha J Margulies DR Salim A Emergency department crystalloid resuscitation of 15 L or more is associated with increased mortality in elderly and nonelderly trauma patients J Trauma 2011 Feb70(2)398-400 doi 101097TA0b013e318208f99b

bull Kasotakis G Sideris A Yang Y de Moya M Alam H King DR Tompkins R Velmahos G Inflammation and Host Response to Injury Investigators Aggressive early crystalloid resuscitation adversely affects outcomes in adult blunt trauma patients an analysis of the Glue Grant database J Trauma Acute Care Surg 2013 May74(5)1215-21 discussion 1221-2 doi 101097TA0b013e3182826e13

bull Neal MD Hoffman MK Cuschieri J Minei JP Maier RV Harbrecht BG Billiar TR Peitzman AB Moore EE Cohen MJ Sperry JL Crystalloid to packed red blood cell transfusion ratio in the massively transfused patient when a little goes a long way J Trauma Acute Care Surg 2012 Apr72(4)892-8 doi 101097TA0b013e31823d84a7

bull Niles SE McLaughlin DF Perkins JG et al Increased mortality associated with the early coagulopathy of trauma in combat casualties J Trauma 2008641459-63

bull Brohi K Singh J Heron M Coats T Acute traumatic coagulopathy J Trauma 2003541127-30

bull Cotton BA Gunter OL Isbell J et al Damage control hematology the impact of a trauma exsanguination protocol on survival and blood product utilization J Trauma 2008641177-82

bull Keneally RJ1 Parsons AM1 Willett PB1 Warm fresh whole blood and thoracic traumain iraq and afghanistan J Emerg Trauma Shock 2015 Jan-Mar8(1)21-5

bull Spinella PC1 Perkins JG Grathwohl KW Beekley AC Holcomb JB Warm fresh whole blood is independently associated with improved survival for patients with combat-related traumatic injuries J Trauma 2009 Apr66(4 Suppl)S69-76

bull Wafaisade A1 Lefering R2 Bouillon B3 Boumlhmer AB4 Gaumlszligler M5 Ruppert M5 TraumaRegister DGU Prehospital administration of tranexamic acid in trauma patients Crit Care 2016 May 1220(1)143

bull Ausset S1 Glassberg E Nadler R Sunde G Cap AP Hoffmann C Plang S Sailliol A Tranexamic acid as part of remote damage-control resuscitation in the prehospital setting A critical appraisal of the medical literature and available alternatives J Trauma Acute Care Surg 2015 Jun78(6 Suppl 1)S70-5

bull CRASH-2 trial collaborators Shakur H Roberts I Bautista R Caballero J Coats T Dewan Y El-Sayed H Gogichaishvili T Gupta S Herrera J Hunt B Iribhogbe P Izurieta M Khamis H Komolafe E Marrero MA Mejiacutea-Mantilla J Miranda J Morales C Olaomi O Olldashi F Perel P Peto R Ramana PV Ravi RR Yutthakasemsunt S Effects of tranexamic acid on death vascular occlusive events and blood transfusion in trauma patients with significant haemorrhage (CRASH-2) a randomised placebo-controlled trial Lancet 2010 Jul 3376(9734)23-32

bull Morrison JJ1 Dubose JJ Rasmussen TE Midwinter MJ Military Application of Tranexamic Acid in Trauma Emergency Resuscitation (MATTERs) Study Arch Surg 2012 Feb147(2)113-9

bull Morrison JJ1 Ross JD Dubose JJ Jansen JO Midwinter MJ Rasmussen TE Association of cryoprecipitate and tranexamic acid with improved survival following wartime injury findings from the MATTERs II Study JAMA Surg 2013 Mar148(3)218-25

ER REBOA

Bottom Line

bull Keep them WARM

bull Little to no crystalloid

bull Hypotension is bad for brain injuries

bull Think about MT early

bull 111 ratio

bull Give TXA early

bull Calcium

bull Fix acidosis

bull Balogh Z McKinley BA Cocanour CS Kozar RA Valdivia A Sailors RM Moore FA Supra-normal trauma resuscitation causes more cases of abdominal compartment syndrome Arch Surg 138637-643 2003

bull Duchesne JC Heaney J Guidry C McSwain N Jr Meade P Cohen M Schreiber M Inaba K Skiada D Demetriades D Holcomb J Wade C Cotton B Diluting the benefits of hemostatic resuscitation A multi-institutional analysis J Trauma Acute Care Surg 2013 Jul75(1)76-82 doi 101097TA0b013e3182987df3

bull Guidry C Gleeson E Simms ER Stuke L Meade P McSwain NE Jr Duchesne JC Initial assessment on the impact of crystalloids versus colloids during damage control resuscitation J Surg Res 2013 Jun 15 pii S0022-4804(13)00568-4 doi 101016jjss201305086 [Epub ahead of print]

bull Perel P Roberts I Ker K Colloids versus crystalloids for fluid resuscitation in critically ill patients Cochrane Database Syst Rev 2013 Feb 282CD000567 doi 10100214651858CD000567pub6

bull Zarychanski R Abou-Setta AM Turgeon AF et al Association of Hydroxyethyl Starch Administration With Mortality and Acute Kidney Injury in Critically Ill Patients Requiring Volume Resuscitation A Systematic Review and Meta-analysis JAMA 2013309(7)678-688 doi101001jama2013430

bull Bulger EM May S Kerby JD Emerson S Stiell IG Schreiber MA Brasel KJ Tisherman SA Coimbra R Rizoli S Minei JP Hata JS Sopko G Evans DC Hoyt DB ROC investigators Out-of-hospital hypertonic resuscitation after traumatic hypovolemic shock a randomized placebo controlled trial Ann Surg 2011 Mar253(3)431-41 doi 101097SLA0b013e3181fcdb22

bull Vassar MJ Fischer RP OBrien PE Bachulis BL Chambers JA Hoyt DB Holcroft JW A multicenter trial for resuscitation of injured patients with 75 sodium chloride The effect of added dextran 70 The Multicenter Group for the Study of Hypertonic Saline in Trauma Patients Arch Surg 1993 Sep128(9)1003-11 discussion 1011-3

bull Cooper DJ Myles PS McDermott FT Murray LJ Laidlaw J Cooper G Tremayne AB Bernard SS Ponsford J HTS Study Investigators Prehospital hypertonic saline resuscitation of patients with hypotension and severe traumatic brain injury a randomized controlled trial JAMA 2004 Mar 17291(11)1350-7

bull Duke MD Guidry C Guice J Stuke L Marr AB Hunt JP Meade P McSwain NE Jr Duchesne JC Restrictive fluid resuscitation in combination with damage control resuscitation time for adaptation J Trauma Acute Care Surg 2012 Sep73(3)674-8 doi 101097TA0b013e318265ce1f

bull Pidcoke HF Aden JK Mora AG Borgman MA Spinella PC Dubick MA Blackbourne LH Cap AP Ten-year analysis of transfusion in Operation Iraqi Freedom and Operation Enduring Freedom increased plasma and platelet use correlates with improved survival J Trauma Acute Care Surg 2012 Dec73(6 Suppl 5)S445-52 doi 101097TA0b013e3182754796

bull Morrison CA Carrick MM Norman MA Scott BG Welsh FJ Tsai P Liscum KR Wall MJ Jr Mattox KL Hypotensive resuscitation strategy reduces transfusion requirements and severe postoperative coagulopathy in trauma patients with hemorrhagic shock preliminary results of a randomized controlled trial J Trauma 2011 Mar70(3)652-63 doi 101097TA0b013e31820e77ea

bull Ley EJ Clond MA Srour MK Barnajian M Mirocha J Margulies DR Salim A Emergency department crystalloid resuscitation of 15 L or more is associated with increased mortality in elderly and nonelderly trauma patients J Trauma 2011 Feb70(2)398-400 doi 101097TA0b013e318208f99b

bull Kasotakis G Sideris A Yang Y de Moya M Alam H King DR Tompkins R Velmahos G Inflammation and Host Response to Injury Investigators Aggressive early crystalloid resuscitation adversely affects outcomes in adult blunt trauma patients an analysis of the Glue Grant database J Trauma Acute Care Surg 2013 May74(5)1215-21 discussion 1221-2 doi 101097TA0b013e3182826e13

bull Neal MD Hoffman MK Cuschieri J Minei JP Maier RV Harbrecht BG Billiar TR Peitzman AB Moore EE Cohen MJ Sperry JL Crystalloid to packed red blood cell transfusion ratio in the massively transfused patient when a little goes a long way J Trauma Acute Care Surg 2012 Apr72(4)892-8 doi 101097TA0b013e31823d84a7

bull Niles SE McLaughlin DF Perkins JG et al Increased mortality associated with the early coagulopathy of trauma in combat casualties J Trauma 2008641459-63

bull Brohi K Singh J Heron M Coats T Acute traumatic coagulopathy J Trauma 2003541127-30

bull Cotton BA Gunter OL Isbell J et al Damage control hematology the impact of a trauma exsanguination protocol on survival and blood product utilization J Trauma 2008641177-82

bull Keneally RJ1 Parsons AM1 Willett PB1 Warm fresh whole blood and thoracic traumain iraq and afghanistan J Emerg Trauma Shock 2015 Jan-Mar8(1)21-5

bull Spinella PC1 Perkins JG Grathwohl KW Beekley AC Holcomb JB Warm fresh whole blood is independently associated with improved survival for patients with combat-related traumatic injuries J Trauma 2009 Apr66(4 Suppl)S69-76

bull Wafaisade A1 Lefering R2 Bouillon B3 Boumlhmer AB4 Gaumlszligler M5 Ruppert M5 TraumaRegister DGU Prehospital administration of tranexamic acid in trauma patients Crit Care 2016 May 1220(1)143

bull Ausset S1 Glassberg E Nadler R Sunde G Cap AP Hoffmann C Plang S Sailliol A Tranexamic acid as part of remote damage-control resuscitation in the prehospital setting A critical appraisal of the medical literature and available alternatives J Trauma Acute Care Surg 2015 Jun78(6 Suppl 1)S70-5

bull CRASH-2 trial collaborators Shakur H Roberts I Bautista R Caballero J Coats T Dewan Y El-Sayed H Gogichaishvili T Gupta S Herrera J Hunt B Iribhogbe P Izurieta M Khamis H Komolafe E Marrero MA Mejiacutea-Mantilla J Miranda J Morales C Olaomi O Olldashi F Perel P Peto R Ramana PV Ravi RR Yutthakasemsunt S Effects of tranexamic acid on death vascular occlusive events and blood transfusion in trauma patients with significant haemorrhage (CRASH-2) a randomised placebo-controlled trial Lancet 2010 Jul 3376(9734)23-32

bull Morrison JJ1 Dubose JJ Rasmussen TE Midwinter MJ Military Application of Tranexamic Acid in Trauma Emergency Resuscitation (MATTERs) Study Arch Surg 2012 Feb147(2)113-9

bull Morrison JJ1 Ross JD Dubose JJ Jansen JO Midwinter MJ Rasmussen TE Association of cryoprecipitate and tranexamic acid with improved survival following wartime injury findings from the MATTERs II Study JAMA Surg 2013 Mar148(3)218-25

Bottom Line

bull Keep them WARM

bull Little to no crystalloid

bull Hypotension is bad for brain injuries

bull Think about MT early

bull 111 ratio

bull Give TXA early

bull Calcium

bull Fix acidosis

bull Balogh Z McKinley BA Cocanour CS Kozar RA Valdivia A Sailors RM Moore FA Supra-normal trauma resuscitation causes more cases of abdominal compartment syndrome Arch Surg 138637-643 2003

bull Duchesne JC Heaney J Guidry C McSwain N Jr Meade P Cohen M Schreiber M Inaba K Skiada D Demetriades D Holcomb J Wade C Cotton B Diluting the benefits of hemostatic resuscitation A multi-institutional analysis J Trauma Acute Care Surg 2013 Jul75(1)76-82 doi 101097TA0b013e3182987df3

bull Guidry C Gleeson E Simms ER Stuke L Meade P McSwain NE Jr Duchesne JC Initial assessment on the impact of crystalloids versus colloids during damage control resuscitation J Surg Res 2013 Jun 15 pii S0022-4804(13)00568-4 doi 101016jjss201305086 [Epub ahead of print]

bull Perel P Roberts I Ker K Colloids versus crystalloids for fluid resuscitation in critically ill patients Cochrane Database Syst Rev 2013 Feb 282CD000567 doi 10100214651858CD000567pub6

bull Zarychanski R Abou-Setta AM Turgeon AF et al Association of Hydroxyethyl Starch Administration With Mortality and Acute Kidney Injury in Critically Ill Patients Requiring Volume Resuscitation A Systematic Review and Meta-analysis JAMA 2013309(7)678-688 doi101001jama2013430

bull Bulger EM May S Kerby JD Emerson S Stiell IG Schreiber MA Brasel KJ Tisherman SA Coimbra R Rizoli S Minei JP Hata JS Sopko G Evans DC Hoyt DB ROC investigators Out-of-hospital hypertonic resuscitation after traumatic hypovolemic shock a randomized placebo controlled trial Ann Surg 2011 Mar253(3)431-41 doi 101097SLA0b013e3181fcdb22

bull Vassar MJ Fischer RP OBrien PE Bachulis BL Chambers JA Hoyt DB Holcroft JW A multicenter trial for resuscitation of injured patients with 75 sodium chloride The effect of added dextran 70 The Multicenter Group for the Study of Hypertonic Saline in Trauma Patients Arch Surg 1993 Sep128(9)1003-11 discussion 1011-3

bull Cooper DJ Myles PS McDermott FT Murray LJ Laidlaw J Cooper G Tremayne AB Bernard SS Ponsford J HTS Study Investigators Prehospital hypertonic saline resuscitation of patients with hypotension and severe traumatic brain injury a randomized controlled trial JAMA 2004 Mar 17291(11)1350-7

bull Duke MD Guidry C Guice J Stuke L Marr AB Hunt JP Meade P McSwain NE Jr Duchesne JC Restrictive fluid resuscitation in combination with damage control resuscitation time for adaptation J Trauma Acute Care Surg 2012 Sep73(3)674-8 doi 101097TA0b013e318265ce1f

bull Pidcoke HF Aden JK Mora AG Borgman MA Spinella PC Dubick MA Blackbourne LH Cap AP Ten-year analysis of transfusion in Operation Iraqi Freedom and Operation Enduring Freedom increased plasma and platelet use correlates with improved survival J Trauma Acute Care Surg 2012 Dec73(6 Suppl 5)S445-52 doi 101097TA0b013e3182754796

bull Morrison CA Carrick MM Norman MA Scott BG Welsh FJ Tsai P Liscum KR Wall MJ Jr Mattox KL Hypotensive resuscitation strategy reduces transfusion requirements and severe postoperative coagulopathy in trauma patients with hemorrhagic shock preliminary results of a randomized controlled trial J Trauma 2011 Mar70(3)652-63 doi 101097TA0b013e31820e77ea

bull Ley EJ Clond MA Srour MK Barnajian M Mirocha J Margulies DR Salim A Emergency department crystalloid resuscitation of 15 L or more is associated with increased mortality in elderly and nonelderly trauma patients J Trauma 2011 Feb70(2)398-400 doi 101097TA0b013e318208f99b

bull Kasotakis G Sideris A Yang Y de Moya M Alam H King DR Tompkins R Velmahos G Inflammation and Host Response to Injury Investigators Aggressive early crystalloid resuscitation adversely affects outcomes in adult blunt trauma patients an analysis of the Glue Grant database J Trauma Acute Care Surg 2013 May74(5)1215-21 discussion 1221-2 doi 101097TA0b013e3182826e13

bull Neal MD Hoffman MK Cuschieri J Minei JP Maier RV Harbrecht BG Billiar TR Peitzman AB Moore EE Cohen MJ Sperry JL Crystalloid to packed red blood cell transfusion ratio in the massively transfused patient when a little goes a long way J Trauma Acute Care Surg 2012 Apr72(4)892-8 doi 101097TA0b013e31823d84a7

bull Niles SE McLaughlin DF Perkins JG et al Increased mortality associated with the early coagulopathy of trauma in combat casualties J Trauma 2008641459-63

bull Brohi K Singh J Heron M Coats T Acute traumatic coagulopathy J Trauma 2003541127-30

bull Cotton BA Gunter OL Isbell J et al Damage control hematology the impact of a trauma exsanguination protocol on survival and blood product utilization J Trauma 2008641177-82

bull Keneally RJ1 Parsons AM1 Willett PB1 Warm fresh whole blood and thoracic traumain iraq and afghanistan J Emerg Trauma Shock 2015 Jan-Mar8(1)21-5

bull Spinella PC1 Perkins JG Grathwohl KW Beekley AC Holcomb JB Warm fresh whole blood is independently associated with improved survival for patients with combat-related traumatic injuries J Trauma 2009 Apr66(4 Suppl)S69-76

bull Wafaisade A1 Lefering R2 Bouillon B3 Boumlhmer AB4 Gaumlszligler M5 Ruppert M5 TraumaRegister DGU Prehospital administration of tranexamic acid in trauma patients Crit Care 2016 May 1220(1)143

bull Ausset S1 Glassberg E Nadler R Sunde G Cap AP Hoffmann C Plang S Sailliol A Tranexamic acid as part of remote damage-control resuscitation in the prehospital setting A critical appraisal of the medical literature and available alternatives J Trauma Acute Care Surg 2015 Jun78(6 Suppl 1)S70-5

bull CRASH-2 trial collaborators Shakur H Roberts I Bautista R Caballero J Coats T Dewan Y El-Sayed H Gogichaishvili T Gupta S Herrera J Hunt B Iribhogbe P Izurieta M Khamis H Komolafe E Marrero MA Mejiacutea-Mantilla J Miranda J Morales C Olaomi O Olldashi F Perel P Peto R Ramana PV Ravi RR Yutthakasemsunt S Effects of tranexamic acid on death vascular occlusive events and blood transfusion in trauma patients with significant haemorrhage (CRASH-2) a randomised placebo-controlled trial Lancet 2010 Jul 3376(9734)23-32

bull Morrison JJ1 Dubose JJ Rasmussen TE Midwinter MJ Military Application of Tranexamic Acid in Trauma Emergency Resuscitation (MATTERs) Study Arch Surg 2012 Feb147(2)113-9

bull Morrison JJ1 Ross JD Dubose JJ Jansen JO Midwinter MJ Rasmussen TE Association of cryoprecipitate and tranexamic acid with improved survival following wartime injury findings from the MATTERs II Study JAMA Surg 2013 Mar148(3)218-25

bull Balogh Z McKinley BA Cocanour CS Kozar RA Valdivia A Sailors RM Moore FA Supra-normal trauma resuscitation causes more cases of abdominal compartment syndrome Arch Surg 138637-643 2003

bull Duchesne JC Heaney J Guidry C McSwain N Jr Meade P Cohen M Schreiber M Inaba K Skiada D Demetriades D Holcomb J Wade C Cotton B Diluting the benefits of hemostatic resuscitation A multi-institutional analysis J Trauma Acute Care Surg 2013 Jul75(1)76-82 doi 101097TA0b013e3182987df3

bull Guidry C Gleeson E Simms ER Stuke L Meade P McSwain NE Jr Duchesne JC Initial assessment on the impact of crystalloids versus colloids during damage control resuscitation J Surg Res 2013 Jun 15 pii S0022-4804(13)00568-4 doi 101016jjss201305086 [Epub ahead of print]

bull Perel P Roberts I Ker K Colloids versus crystalloids for fluid resuscitation in critically ill patients Cochrane Database Syst Rev 2013 Feb 282CD000567 doi 10100214651858CD000567pub6

bull Zarychanski R Abou-Setta AM Turgeon AF et al Association of Hydroxyethyl Starch Administration With Mortality and Acute Kidney Injury in Critically Ill Patients Requiring Volume Resuscitation A Systematic Review and Meta-analysis JAMA 2013309(7)678-688 doi101001jama2013430

bull Bulger EM May S Kerby JD Emerson S Stiell IG Schreiber MA Brasel KJ Tisherman SA Coimbra R Rizoli S Minei JP Hata JS Sopko G Evans DC Hoyt DB ROC investigators Out-of-hospital hypertonic resuscitation after traumatic hypovolemic shock a randomized placebo controlled trial Ann Surg 2011 Mar253(3)431-41 doi 101097SLA0b013e3181fcdb22

bull Vassar MJ Fischer RP OBrien PE Bachulis BL Chambers JA Hoyt DB Holcroft JW A multicenter trial for resuscitation of injured patients with 75 sodium chloride The effect of added dextran 70 The Multicenter Group for the Study of Hypertonic Saline in Trauma Patients Arch Surg 1993 Sep128(9)1003-11 discussion 1011-3

bull Cooper DJ Myles PS McDermott FT Murray LJ Laidlaw J Cooper G Tremayne AB Bernard SS Ponsford J HTS Study Investigators Prehospital hypertonic saline resuscitation of patients with hypotension and severe traumatic brain injury a randomized controlled trial JAMA 2004 Mar 17291(11)1350-7

bull Duke MD Guidry C Guice J Stuke L Marr AB Hunt JP Meade P McSwain NE Jr Duchesne JC Restrictive fluid resuscitation in combination with damage control resuscitation time for adaptation J Trauma Acute Care Surg 2012 Sep73(3)674-8 doi 101097TA0b013e318265ce1f

bull Pidcoke HF Aden JK Mora AG Borgman MA Spinella PC Dubick MA Blackbourne LH Cap AP Ten-year analysis of transfusion in Operation Iraqi Freedom and Operation Enduring Freedom increased plasma and platelet use correlates with improved survival J Trauma Acute Care Surg 2012 Dec73(6 Suppl 5)S445-52 doi 101097TA0b013e3182754796

bull Morrison CA Carrick MM Norman MA Scott BG Welsh FJ Tsai P Liscum KR Wall MJ Jr Mattox KL Hypotensive resuscitation strategy reduces transfusion requirements and severe postoperative coagulopathy in trauma patients with hemorrhagic shock preliminary results of a randomized controlled trial J Trauma 2011 Mar70(3)652-63 doi 101097TA0b013e31820e77ea

bull Ley EJ Clond MA Srour MK Barnajian M Mirocha J Margulies DR Salim A Emergency department crystalloid resuscitation of 15 L or more is associated with increased mortality in elderly and nonelderly trauma patients J Trauma 2011 Feb70(2)398-400 doi 101097TA0b013e318208f99b

bull Kasotakis G Sideris A Yang Y de Moya M Alam H King DR Tompkins R Velmahos G Inflammation and Host Response to Injury Investigators Aggressive early crystalloid resuscitation adversely affects outcomes in adult blunt trauma patients an analysis of the Glue Grant database J Trauma Acute Care Surg 2013 May74(5)1215-21 discussion 1221-2 doi 101097TA0b013e3182826e13

bull Neal MD Hoffman MK Cuschieri J Minei JP Maier RV Harbrecht BG Billiar TR Peitzman AB Moore EE Cohen MJ Sperry JL Crystalloid to packed red blood cell transfusion ratio in the massively transfused patient when a little goes a long way J Trauma Acute Care Surg 2012 Apr72(4)892-8 doi 101097TA0b013e31823d84a7

bull Niles SE McLaughlin DF Perkins JG et al Increased mortality associated with the early coagulopathy of trauma in combat casualties J Trauma 2008641459-63

bull Brohi K Singh J Heron M Coats T Acute traumatic coagulopathy J Trauma 2003541127-30

bull Cotton BA Gunter OL Isbell J et al Damage control hematology the impact of a trauma exsanguination protocol on survival and blood product utilization J Trauma 2008641177-82

bull Keneally RJ1 Parsons AM1 Willett PB1 Warm fresh whole blood and thoracic traumain iraq and afghanistan J Emerg Trauma Shock 2015 Jan-Mar8(1)21-5

bull Spinella PC1 Perkins JG Grathwohl KW Beekley AC Holcomb JB Warm fresh whole blood is independently associated with improved survival for patients with combat-related traumatic injuries J Trauma 2009 Apr66(4 Suppl)S69-76

bull Wafaisade A1 Lefering R2 Bouillon B3 Boumlhmer AB4 Gaumlszligler M5 Ruppert M5 TraumaRegister DGU Prehospital administration of tranexamic acid in trauma patients Crit Care 2016 May 1220(1)143

bull Ausset S1 Glassberg E Nadler R Sunde G Cap AP Hoffmann C Plang S Sailliol A Tranexamic acid as part of remote damage-control resuscitation in the prehospital setting A critical appraisal of the medical literature and available alternatives J Trauma Acute Care Surg 2015 Jun78(6 Suppl 1)S70-5

bull CRASH-2 trial collaborators Shakur H Roberts I Bautista R Caballero J Coats T Dewan Y El-Sayed H Gogichaishvili T Gupta S Herrera J Hunt B Iribhogbe P Izurieta M Khamis H Komolafe E Marrero MA Mejiacutea-Mantilla J Miranda J Morales C Olaomi O Olldashi F Perel P Peto R Ramana PV Ravi RR Yutthakasemsunt S Effects of tranexamic acid on death vascular occlusive events and blood transfusion in trauma patients with significant haemorrhage (CRASH-2) a randomised placebo-controlled trial Lancet 2010 Jul 3376(9734)23-32

bull Morrison JJ1 Dubose JJ Rasmussen TE Midwinter MJ Military Application of Tranexamic Acid in Trauma Emergency Resuscitation (MATTERs) Study Arch Surg 2012 Feb147(2)113-9

bull Morrison JJ1 Ross JD Dubose JJ Jansen JO Midwinter MJ Rasmussen TE Association of cryoprecipitate and tranexamic acid with improved survival following wartime injury findings from the MATTERs II Study JAMA Surg 2013 Mar148(3)218-25

Questions

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