ACTEP2014: How to maximise resuscitation in trauma 2014

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HOW TO MAXIMIZE YOUR RESUSCITATION POTENTIAL

IN TRAUMA PATIENTS ?

NARAIN CHOTIROSNIRAMIT MD. TRAUMA AND CRITICAL CARE UNIT,

DEPARTMENT OF SURGERY, FACULTY OF MEDICINE CHIANGMAI UNIVERSITY

INTRODUCTION

Populations number

Number of death

Estimated road traffic death

rate per 100,000

populations

Niue 1,465 1 68.3

Dominican Republic 9,927,320 2,470 40.1

Thailand 69,122,232 13,365 38.1

Venezuela 28,979,857 7,714 37.2

Iran 73,973,628 23,247 34.1

Nigeria 158,423,184 5,279 33.7

South Africa 50,132,820 14,804 31.9

•  PERMISSIVE HYPOTENSION

•  BEDSIDE MONITORING FOR

RESUSCITATION

•  HEMOSTATIC RESUSCITATION

•  RESUSCITATIVE ENDOVASCULAR

BALLOON OCCLUSION FOR AORTA

PERMISSIVE HYPOTENSION

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Kenneth L. MaYox

William H. Bickell, et al. N Engl J Med. Volume 331, Oct 1994 :1105-‐1109


Single center , prospec\ve , randomized , controlled trial in Houston 1989-‐1992.

598 adult trauma with penetra\ng torso injury & SBP < 90 mm Hg.

1. Immediate resuscita\on ( IR )

2. Delayed resuscita\on (DR)


“Hypotensive pa\ents with penetra\ng injuries of the chest and abdomen :

Deferring fluid admin : improves outcome”

William H. Bickell, et al. N Engl J Med. Volume 331, Oct 1994 :1105-‐1109


Favorable results in delayed fluid resuscita\on Capone, AC, Safar, P, Stezoski, W, et al. J Am Coll Surg 1995; 180:49

Owens, TM, Watson, WC, Prough, DS, et al. J Trauma 1995; 39:200.. Silbergleit, R, Satz, W, McNamara, RM, et al. Acad Emerg Med 1996; 3:922.

Kim, SH, Stezoski, SW, Safar, P, et al. J Trauma 1997; 42:213. Solomonov, E, Hirsh, M, Yahiya, A, Krausz, MM. Crit Care Med 2000; 28:749.

DuZon, RP, Mackenzie, CF, Scalea, TM. J Trauma 2002; 52:1141.

McKinley, BA, Valdivia, A, Moore, FA. Curr Opin Crit Care 2003; 9:292.

Mapstone, J, Roberts, I, Evans, P. J Trauma 2003; 55:571.


Excessive crystalloid : can cause abdominal compartment syndrome (ACS).

Normal resuscita\on : decrease incidence of ACS.

Balogh , Moore, et al. Arch Surg. 2003 Jun;138(6):637-‐42


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Just for

penetra

\ng inju

ry !!!

The pa\ent who would probably not tolerate prolonged hypotension

1. The head-‐injured hypotensive pa\ent 2. Blunt trauma pa\ent with mul\ple sites of blood loss

3. Extremely old



BLUNT TRAUMA ?

George K, et al J Trauma Acute Care Surg Volume 74, Number 5, 1215-‐1222

George K, et al J Trauma Acute Care Surg Volume 74, Number 5, 1215-‐1222 George K, et al J Trauma Acute Care Surg Volume 74, Number 5, 1215-‐1222

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ALI/ARDS MOF

ABD COMPARTMENT SSI

•  High volume of crystalloid resuscita\on :

Prolonged ven`lator `me

Prolonged ICU stay

Prolonged hospital LOS

•  Dose-‐dependent increase morbid complica\ons

(ALI/ARDS, MOF, abdominal compartment syndrome, SSIs)

CONCLUSION CONCLUSION


HEAD INJURY ?

PERMISSIVE HYPOTENSION HEAD INJURY ?

•  Impaired cerebral autoregula\on due to TBI makes cerebral perfusion dependent on adequacy of sBP

•  sBP < 90 mmHg early aoer TBI : 150% increase in mortality

Chesnut RM, Marshall LF, Klauber MR, et al. J Trauma 1993;34:216–22


TARGET BLOOD PREESURE ? Fluid administra\on to maintain the MAP in

the 60-‐80 mmHg range is advisable and appropriate.

Hai SA.J Pak Med Assoc. 2004 Aug;54(8):434-‐6.

PERMISSIVE HYPOTENSION TARGET BLOOD PREESURE ?

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•  80 rats 8 groups : Different target MAPs (control, 40, 50, 60, 70, 80, 90 mmHg, and sham) on

fluid resuscita\on of uncontrolled hemorrhagic shock.


•  Conclusion Too-‐low MAP resuscita\on results in

Less blood loss and lower fluid therapy

Greater proinflammatory cytokine response

Higher mortality than resuscita\on at higher MAP of uncontrolled hemorrhagic shock.

MAP of 60 mmHg is the target BP for hypotensive resuscita\on.


Uncontrolled hemorrhage, hypotensive resuscita\on to MAP 60 mmHg may be the op\mal target MAP

Yu YH, et al. Resuscita`on 2009;80:1424–30.


If Bleeding stop

No Permissive hypotension

WARNING

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BEDSIDE MONITORING

OF RESUSCITATION

FAST

Extend to Rt/Lt Chest Cavity E-‐FAST

•  Hemothorax •  Pneumothorax

sensi\vity 92-‐100% specificity 91-‐100%

Husain LF, Hagopian L, Wayman D, Baker WE, Carmody KA. Sonographic diagnosis of pneumothorax. J Emerg Trauma Shock. 2012;5(1):76–81.

Sign of Pneumothorax

-‐ Loss of lung sliding sign -‐ “Absent of Seashore sign” or “Stratosphere sign” or “Barcode sign”

Rao R. Ivatury

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BEDSIDE MONITORING OF RESUSCITATION

Invasive hemodynamic monitoring in the trauma bay ?


Underresuscita\on & overresuscita\on have life-‐threatening consequences.

Balogh Z,et al. Am J Surg. 2002;184:538Y543.

Kasotakis G, et al. J Trauma Acute Care Surg. 2013;74:1215-‐1221.


Hypothesis :

LTTE is a useful tool to guide therapy in hypotensive trauma pa\ents during the ini\al phase of resuscita\on


PATIENTS AND METHODS

•  Pa\ents at any point during the ini\al presenta\on or en route had : sBP < 100 mmHg Mean BP < 60mmHg Pulse > 120 beats /min

Randomized : LTTE performed (LTTEp) Not performed (non-‐LTTE)

1St July – 31st December 2012.

•  Windows obtained included the following:

Parasternal long

Parasternal short

Apical and subxyphoid.


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•  Repor\ng the Results of the LTTE Contrac\lity

Fluid status

Pericardial effusion.


•  Fluid Status IVC size and collapsibility Hypovolemic : IVC < 2 cm and collapsible. Ventricular filling Hypovolemia : Hyperdynamic heart. (ventricle that is closing nearly 100%,with almost

no blood at the end of systole)


Collapsible inferior vena cava, long axis view

Inferior vena cava plethora long axis view

Fluid Status

IVCD (mm)

Caval Index (%)

RAP (mmHg)

< 20 > 50 5 < 20 < 50 10 > 20 < 50 15 > 20 0 20

Spontaneous breathing à Collapsibility

Gunst et al. Bedside Echocardiographic Assessment for Trauma/Cri;cal Care: The BEAT Exam. J Am Coll Surg Vol. 207, No. 3, Sep 2008

Inferior vena cava assessment

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•  Contrac\lity Good or poor.

No calcula\ons of the ejec\on frac\on

No comments of ventricular wall mo\on abnormali\es.

Assessment of global heart func\on only.


M-‐mode tracing demonstra\ng excellent contrac\lity. RV: right ventricle, LV: leo ventricle

M-‐mode tracing demonstra\ng poor contrac\lity. LV: leo ventricle

•  Pericardial Effusion Presence or the absence of effusion only No commen\ng on the physiology of the

heart.


Cardiac tamponade, subxiphoid view. RV: right ventricle, RV: right atrium, LV: leo ventricle, LA: leo atrium, PE: pericardial effusion

215 pa\ents in the study. 92 LTTEp 123 non-‐LTTE

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Conclusion •  LTTE was a useful tool to guide therapy. The LTTEp group to receive less IVF and

aided in the resuscita\on process. •  The appropriate image-‐guided resuscita\on perhaps contributed to decreased mortality in the LTTEp group

HEMOSTATIC RESUSCITATION

Initial Assessment and Management

Direct pressure/ tourniquet

Reduce pelvic volume

Operation

Hemostatic Agents

Splint fractures

Angio-embolization

Hemostatic resuscitation

What can I do about shock?

INTERVENTIONS

9th

Damage Control Resuscita\on

DCR

Permissive Hypotension / Restric\ve Fluid Resuscita\on

Damage Control Opera\on / Surgery

(DCO / DCS)

Hemosta\c Resuscita\on / Balanced Blood Product Resuscita\on

John B Holcomb

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Timing and mechanism of trauma\c death.

Kauvar DS, Lefering R, Wade CE. J Trauma. 2006;60:S3–S11.

Coagulopahy in trauma pa\ents

Coagulopathy

Acidosis Hypothermia

Lethal triads Up to 30% of blood transfused case require a massive transfusion

( > 10 u of blood in the first 24 hrs of admission) Como JJ, DuYon RP, Scalea TM, et al. Transfusion. 2004; 44:809–813.

Malone DL, Dunne J, Tracy Jk, et al. J Trauma. 2003;54:898 –905.

Damage Control Resuscita\on

Massive Transfusion

1–3% of civilian trauma Mortality rates 50–70% Fakhry SM, Sheldon GF. American Associa`on of Blood Banks, 1994.

Bri`sh CommiZee for Standards in Haematology. BrJ Haematol 2006; 135:634-‐41

Acute coagulopathy of trauma is ooen

present before any resuscita\ve efforts Brohi K, Singh J, Heron M, Coats T. J Trauma. 2003;54:1127–1130.

MacLeaod JB, Lynn M, McKenney MG, et al. J Trauma. 2003; 55:39–44.

Acute traumacc coagulopathy (ATC)

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•  Prospec\ve, observa\onal study •  Popula\ons: 45 trauma pa\ents •  Compare: the on-‐scene coagula\on profile at the scene of the accident, before fluid administra\on, and on hospital admission Rela\on between coagula\on status and injury severity score

on-‐scene and in the emergency room.

On Scene

ER

Conclusion : Coagulacon abnormalices Appear very early ader injury Before fluid administracon 60% of pacents. Upon hospital admission, the on-‐scene

coagulopathy was the same or worsened in 96% of the pacents



Trauma + Shock •  Trauma

–  Increase \ssue injury, inflamma\on

–  Increase thrombin produc\on •  Cleave fibrinogen to fibrin •  Poten\ate procoagulant process •  Ac\va\on of protein C

–  Consump\ve coagulopathy

•  Hypoperfusion –  Elevate levels of protein C –  Elevate thrombomodulin -‐> Thrombomodulin-‐bound thrombin •  Ac\va\on of protein C •  Impairing clot forma\on •  Fibrinolysis is enhanced

–  Release of t-‐PA from vascular endothelial cells and subsequent hyperfibrinolysis

How can we predict of MT ? Clinical scoring system

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TASH Score TASH Score

McLaughlin score McLaughlin score

McLaughlin DF. J Trauma. 2008;64:S57–S63.

ABC score ABC score

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ABC score

ABC > 2, 75% sensicve, 86% specific

Prediccve Tools for MT in Trauma ABC TASH McLaughlin Hsu et al.

BP ≤ 90 SBP (categorical)

< 110 Hct < 32% pH < 7.25

-‐

HR ≥ 120 > 120 > 105 -‐

FAST FAST+ FAST+ -‐ FAST+

Mechanism Penetracng Complex long bone or pelvic

Fx -‐ -‐

Demographics -‐ Male -‐ -‐

LAB -‐ Hb (categorical), BE (categorical)

Hct < 32% pH < 7.25

BE < -‐5 INR > 1.5

AUROC 0.859 0.887 0.747 0.859

Riskin DJ, Tsai TC, Riskin L, et al. J Am Coll Surg. 209( 2), August 2009, 198-‐205

RESULT RESULT

•  Lower the mortality

•  High raco of FFP: Early studies showed •  Higher ARDS and MOF incidences

•  Higher complicacons (Sepcc shock, VAP, abdominal compartment syndrome, ACS, heart failure, liver failure)

J Am Coll Surg. 2009;209(2):198–205. PROMMTT Study. JAMA Surg 2013; 148(2):127-‐136.

PRC:FFP:Plt ra\o = 1:1:1

Brown LM. J Trauma. 2011;71: S358–S363

Retrospec\ve mul\center cohort study of 437 massively transfused trauma pa\ents

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METHOD

•  Included studies 1613 references were

1532 references were excluded

81 ar\cles obtained

Final 8 ar\cles

•  This meta-‐analysis supports the use of

plasma in ra\os of 1:2 plasma:RBC

•  Did not iden\fy addi\onal benefits of 1:1 over 1:2 transfusion ra\os.

CONCLUSION

OTHER HEMOSTATIC AGENTS

r FACTOR VII

RCT in 301 pa\ents with severe blunt and/or penetra\ng trauma

Significant reduc\on of red cell transfusion

Mortality : not significant Boffard KD. J Trauma 2005;59:8-‐15

CRYOPRECIPITATE

•  In the resuscita\on of bleeding trauma pa\ents Early fibrinogen infusion associated with

favorable outcomes in uncontrolled studies

Rourke C, et al. J Thromb Haemost. 2012;10:1342Y1351. Schochl H, et al. Crit Care. 2011; 15:R83.

Shakur H, et al. Lancet 2010; 376(9734):23.

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ANTIFRIBINOLYTIC THERAPY

Randomized controlled, mulc-‐center trial 274 hospitals , n = 20,211 trauma pts.

Result: 28-‐day Mortality Rate:

14.5% vs. 16% ; p = 0.0035

Mortality rate from uncontrolled bleeding: 4.9% vs. 5.7% ; p = 0.0077

Mortality rate in trauma(ader 3 hrs): 4.4% vs. 3.1% ; p=0.004

Shakur H, et al. Lancet 2010; 376(9734):23.

Loading dose of 1g over 10 min. then 1g infusion for 8 hrs

vs. Placebo

MASSIVE TRANSFUSION PROTOCOL MAHARAJ NAKORN CHIANGMAI

2 FEBRUARY 2014

MTP Maharaj Nakorn Chiangmai


Indica\ons for ER

Ini\al resuscita\on > 2 liters of

isotonic crystalloid ร่วมกับมีข้อใดข้อหนึ่งต่อไปนี้

HR > 120 bpm

sBP < 90 mmHg

Serum pH < 7.2

Base excess < -‐5

PRC : FFP : Plt = 4:2:2

1

2

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3

4


•  1 Box of MTP = PRC:FFP:Plt = 4:2:2

(PRC -‐> ini\al crossmatch/first-‐stage)

•  Need 15 min for 1st box

•  BOX 3 : full crossmatch

5

6

7

8 9

10

ข้อมูล กพ-‐ตค 2557 เพศ

ช่วงอายุ ช ญ ผลรวมทั้งหมด 10-‐19 10 0 10 20-‐29 12 2 14 30-‐39 13 0 13 40-‐49 8 3 11 50-‐59 13 2 15 60-‐69 3 0 3 70-‐79 4 0 4 80-‐89 2 0 2

ไม่ทราบอายุ 3 0 3 ผลรวมทั้งหมด 68 7 75


Type In 1 hr 2nd hr > 2 hr Total

PRC 316 98 425 839

FFP 188 42 321 551

Plt 178 53 292 523

Cryo 20 0 80 100


Resuscita\ve Endovascular Balloon Occlusion of the Aorta

(REBOA)

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REBOA

Balloon occlusion : an adjunct for shock was reported during the Korean War.

Hughes CW.. Surgery. 1954;36:65-‐68.

•  Ra\onale : Aor\c occlusion supports myocardial and

cerebral perfusion un\l resuscita\on can be ini\ated and hemostasis obtained. Same goals of open aor\c cross clamping. REBOA : less invasive , decrease morbidity.

White JM, et al. Surgery. 2011;150:400-‐409. Burlew CC, et al. J Trauma Acute Care Surg. 2012;73(6): 1359-‐1363; discussion

1363-‐1364.

Dorlac WC, et al. J Trauma. 2005;59(1):217-‐222.

REBOA

Intraopera\ve angiogram performed through a side-‐port of the sheath demonstrates renal arteries aoer stent deployment with balloon s\ll inflated

O’Donnell ME et al. J Vasc Surg, 44(1), 211-‐5

Aor\c balloon have

also been used to control

hemorrhage in civilian

abdominal trauma. Gupta BK, et al. J Trauma 1989; 29 : 861-‐5

Wolf Rk, et al. J Vasc Surg 1986; 4: 95-‐7.

REBOA

5 steps each with specific procedural considera\ons

1. Arterial access

2. Balloon selec\on and posi\oning

3. Balloon infla\on

4. Balloon defla\on

5. Sheath removal

REBOA Step 1

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•  STEP 2: SELECTION AND POSITIONING OF THE BALLOON

Selec\on of a Balloon : Examples of compliant balloons

(1) Coda balloon (Cook Medical): 32-‐40 mm, 14 Fr

(2) Reliant balloon (Medtronic): 10-‐46 mm, 12 Fr

(3) Berenstein balloon (Boston Scien`fic): 11.5 mm, 6 Fr.

REBOA Step 2

Pelvic binder in place with REBOA catheter in right groin. Binder was moved up and modified to facilitate placement of REBOA.

Step 2

•  STEP 3: INFLATION OF THE BALLOON AND SECURING OF THE APPARATUS

Infla\on of the Balloon (should be under fluoroscopic guidance).

Mix : 1⁄2 & 1⁄2 solu\on of sterile saline and iodinated contrast.

REBOA

Assistant should monitor and communicate the “big three” factors for successful REBOA:

1. mean arterial pressure

2. maintenance of posi`on

3. maintenance of occlusion (balloon infla`on).

REBOA

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•  STEP 4: DEFLATION OF THE BALLOON Reperfusion syndrome.

•  STEP 5: REMOVAL OF THE BALLOON AND SHEATH Closure of the arteriotomy site (suture)

REBOA •  Aor\c occlusion \me of 40 mins.

Op\mal to control hemorrhagic shock

Preven\ng the biological side effects

of the ischemia/reperfusion injury.

Jean-‐Philippe Avaro, et al. J Trauma . 2011 : 71 (3)

REBOA

Brenner ML, Moore LJ, Dubose JJ, et al. J Trauma. 2013 Sept 75(3), 506-‐511

Pa\ent 1 2 3 4 5 6 Age 62 24 59 25 40 27 Sex M M M M M F Mechanism injury MVC GSW GSW MVC MCC ATV Injury Severity Score (ISS) 28 50 9 25 48 43

SBP before REBOA 70 70 0 60 70 85 SBP aoer REBOA 135 122 100 110 130 125 Cardiac arrest before REBOA No No Yes No No NO

Time to occlusion 5 4 4 6 6 6 Time of occlusion 12 16 70 60 65 36 Outcome Alive Alive Alive Alive Brain

death Death


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•  REBOA resulted in : Mean (SD) increase in BP of 55 (20) mm Hg Mean (SD) aor\c occlusion \me was 18

(34) mins. No REBOA-‐related complica\ons. No hemorrhage-‐related mortality.


REBOA

The Endovascular Skills for Trauma and Resuscita\ve Surgery (ESTARS) curriculum has been developed.

Stannard A, et al . J Trauma. 2011;71(6):1869-‐1872. Villamaria CY, et al. 72nd Annual Mee`ng of the AAST and Clinical Congress of Acute Care Surgery.

BEST course

ALL PERFORM IN OR (NEED FLUOROSCOPY)

POSSIBLE IN ER ?

ScoZ DJ, et al. J Trauma Acute Care Surg. Volume 75, Number 1 122-‐128

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Accurate balloon posi\oning

87.5% VS 100%.

One device entered a right renal artery

Similar increases in MAP, caro\d blood flow, and par\al pressure of brain oxygena\on

REBOA POSSIBLE TO DO IN ER

Trauma with Hypotension (Extremis)

Access Common Femoral artery for A-‐Line or REBOA

CXR Possible Aorcc injury ?

YES NO NO REBOA

FAST Posicve ?

YES

Posicon REBOA in Zone I Inflate and

proceed to laparotomy

NO Pelvic X-‐RAY Fracture ?

Posicon REBOA in Zone I

Inflate and Resuscitate

YES Posicon REBOA

in Zone III Inflate and Resuscitate

NO

•  PERMISSIVE HYPOTENSION

•  BEDSIDE MONITORING FOR

RESUSCITATION

•  HEMOSTATIC RESUSCITATION

•  RESUSCITATIVE ENDOVASCULAR

BALLOON OCCLUSION FOR AORTA

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ACTEP2014: How to maximise resuscitation in trauma 2014

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Transcript of ACTEP2014: How to maximise resuscitation in trauma 2014