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vooruitstrevend in perioperatieve zorgafdeling Anesthesiologie
TRAUMA
Holger Baumann MD
WHY TRAUMA?
Number 1 Killer
40 % uncontrolled hemorrhage
25 % coagulopathic in the ED
Krug, Am J Public Health 2000Sauaia, J Trauma 1995
Brohi, J Trauma 2003Maegele Shock 2006
Brohi, Curr Opp Crit Care 2007Frith, J Thromb 2010
Trauma & Coagulopathy
STOP The Bleeding Campaign
S creen for risk of bleeding/coagulopathty
T reat bleeding coagulopathy
O bserve response to intervention
P revent secondary bleeding / coagulopathy
Rossaint, Crit Care 2013www.advancedbleedingcare.org
STOP The Bleeding Campaign
Screen: Scores Labor
Treat: FFP Fibrinogeen TRX PCC rFVIIa
Observe: PT aPTT ROTEM/TEG
Prevent: Preconditions
Screen for risk of bleeding/coagulopathy
SCORES:
ABCPenetrating mechanism
ED SBP <90 mm
ED HR >120/min
Positive FAST
Nunez, J Trauma 2009 Cotton J Trauma 2010
Krumrei J Trauma 2012Yucsel J Trauma 2006
TASH
SCORES:
Trigger for MT
OR for MT 24 OR MT 24 +hemorrhagic death
OR MT 6 + hemorragic death
INR>1,5 2,2 2,5 3,9SBP < 90 mmHg 1,9 1,7 1,5Hb < 6,6 mml/l 1,8 1,8 2,0BD > 6,0 1,8 2,0 3,0HR > 120 bpm 1,1 1,2 1,2Penetrating 1,0 0,9 1,2dFAST + 1,9 1,8 1,9
Modified fromCalcutt, J Trauma 2013 (PROMMT)
MTS ≥ 2
MT 24 MT 24 + hemorrhagic death
MT 6 + hemorrhagic death
Sensitivity % 85 85 90
Specificity % 41 41 39
PPV % 31 33 39
NPV % 89 89 95
OR MT 3,9 3,9 6,0
Modified fromCalcutt, J Trauma 2013 (PROMMTT)
Base Deficite
BD <= 2 BD >2 - 6 BD >6-10 BD> 10Blood products 1,5 4,5 10,3 20,3
TASH Score 3,5 6,1 10,6 14,3Mortality % 7,4 12 23 51,3
Action? Watch Consider Act Prepare MTP
modifiedRec 11 Mutschler, Crit Care 2013
1C
Shock Index ?
BD≤2 BD>2-6,0 BD>6,0-10,0 BD<10,0 BD≤2 BD>2-6,0 BD>6,0-10,0 BD<10,0
SI < 0,6 SI 0,6-1,0 SI 1,0-1,4 SI ≥ 1,4 SI < 0,6 SI 0,6-1,0 SI 1,0-1,4 SI ≥ 1,4
modifiedMutschler, Crit Care 8- 2013
Conventioneel Lab. vs POC
Standard-Lab Point of Care(ROTEM/TEG)
Evaluatie voor bloeding NO YES
Tijd tot uitslag 30-60 min. 5-15 min.
Hyperfibrinolyse NO YES
Sterkte van stolsel NO YES
Conventioneel Lab. vs POC
Standard-LabPoint of Care(ROTEM/TEG)
Evaluatie voor bloeding NO YES
Tijd tot uitslag 30-60 min. 5-15 min.
Hyperfibrinolyse NO YES
Sterkte van stolsel NO YES
Logistics?Resources? Costs?QA?Training?
POC - thrombo…..• Admission Rapid Thrombelastography Can Replace Conventional Coagulation Tests
in the Emergency Department Experience With 1974 Consecutive Trauma Patients
• Trauma Bleeding Management: The Concept of Goal-Directed Primary Care / schochl
• Screenshots artikel / literture unten diskussion
Monitoring:
..routine practice include the measurement of INR, APTT, fibrinogen and platelets. INR and APTT alone should not be used to guide haemostatic therapy.
.. ..Thrombelastometry to assist in guiding haemostatic therapy.
modifiedRec 12 Spahn, Crit Care 2013
1C
2C
Holcomb, Ann Surg 2012
FIB. - CRYO - FFP
Fibrinogen FFP PCC
Content Fib. constant inconsistent constant
Time admission Immediately 30 min. Immediately
FFP’s – R24
Early treatment with thawed FFP in patients with massive bleeding. Initial dose is 10 to 15 ml/kg.
Spahn, Crit Care 2013
1B
PCC
+ -Rapid reversal of INR Verschillende concentraten
Small volume Prothrombotic risk ( 1,8%*)
No blood type matching No volume effect
Allercig effects?
*Dentali Thrombosis Hemost. 2011
PCC
Emergency reversal of Vit. K-dependent oral anticoagulants.
..PCC ..in the bleeding patient with thromboelastic evidence of delayed coagulaton ininiation.
Rec 31 Spahn, Crit Care 2013
1C
1B
Tranexminezuur (TRX)
..as early as possible to the bleeding patient
..within 3 h after injury
Consider TRX en route to the hospital
Rec 31 Spahn, Crit Care 2013
Tranexminezuur (TRX)
1A
1B
1C
Observe Response to Intervention
• Clinical
• ROTEM
•
Prevent secondary coagulopathy
• Damage control
• Rewarming
• Restore physiology
• No delay
‘De drie eenheid’
Hemodilutie - BloedproduktenWhole blood – 1:1:1 approach
650 ml koud spulHb 5.5 mmol/l (8.9 g/dl)Thr. 75 * 109 Plasma factors 70 %Fibrinogen: 0,5 -1 g (?)
Armand, Transf Medicine Reviews 2003 Como, Transfusion 2004
500 mL Warm500 mL WarmHct: 38-50%Hct: 38-50%Plt: 150-400K Plt: 150-400K Coags: 100%Coags: 100%
1500 mgFibrinogen
Massaal bloedtransfusie protocol @
How do u sweet’n your coffee?
rFVIIa in Trauma
Consider rFVIIa after “conventional” therapy,
if
rFVIIa(Novoseven): 90micg/kg BW
pH > 7,2Temp. > 35,0CFibrinogen > 100 mg/dl or FIBTEM >12 mmThrombocytes > 50/nl or Extem > 45mmHyperfibrinolysis ruled out/therapy
No surgical/IR therapy
REC 33: Spahn, Crit Care 2013
2C
Zorg voor heldere lokale protocollen.Multidisciplinaire aanpak
Voorlichting en training Behandel coagulopathieën
• Basale behandeling• TRX• FFP/FIB• MTP • rFVIIa
A failure in planning is a plan for failureS03E08 Star Wars The Clone Wars
En nu?
vooruitstrevend in perioperatieve zorgafdeling Anesthesiologie
Fibrinogen / Cryoprecipitate
Recommendation 26. We recommend treatment with fibrinogen concentrate or cryoprecipitate if significant bleeding is accompanied by thrombelastometric signs of a functional fibrinogen deficit or a plasma fibrinogen level of less than 1.5 to 2.0 g/l (Grade 1C).
No trauma trials - extrapolation from haemophilia and congenital afibrinogenaemia
Probably give if fibrinogen < 1 g/l
Dose - know your local formulation (cryo not licensed outside UK). Enough to give > 1 g/l
Recommendation
RBC’s Hb 4,4-5,6 mmol/l 1C 17 ATIII No 1C 26
DDAVP Not routinely 2C 30
Platelets > 50000 > 100000 in TBI
1C2C 28
Calcium ≥ 1,0 mmol/l 1C 25