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Management of the Bleeding Trauma Patient: Concepts in
Damage Control Resuscitation
Courtney Sommer, MD MPH Duke Trauma Symposium
March 12, 2015
Obligatory Traumatologist Slide
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Rhee et al. Ann of Surg 2014 nationaltraumainstitute.org
• In 2010 trauma was leading cause of death for
Americans under 47 years old
• 2000-2010 trauma leading cause of death for
Americans 0-56 years
• Remains the leading cause of years of life lost
– Trauma 30%
– Cancer 16%
– Heart Disease 12%
2000-2010 Trauma Deaths by Age
3 Rhee et al. Ann of Surg 2014
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What Do People Die of?
4 www.cdc.gov
What Do People Die of?
• Hemorrhage
– 35% pre-hospital deaths
– 40% deaths within first 24 hours
• Leading cause of preventable death
• Morbidity and mortality strongly associated with
bleeding and need for transfusion
5 Kauvea et al. J Trauma 2006
Damage Control Resuscitation • Early hemorrhage control
– OR – IR
• Permissive hypotension – Minimize crystalloid (dilution)
• Target early coagulopathy
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Damage Control Surgery • Not a new concept • Ugly • Necessary evil in order to restore hemodynamics in
the ICU
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www.trauma.org Rotondo et al. J Trauma 1993
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Damage Control Surgery
Endovascular Control of Hemorrhage • Spleen • Liver • Kidney • Pelvis
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Endovascular Control of Hemorrhage
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Endovascular Control of Hemorrhage
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Endovascular Control of Hemorrhage
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Endovascular Control of Hemorrhage
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Endovascular Control of Hemorrhage
Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA)
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Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA)
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Summary Early Hemorrhage Control • Recognize injury pattern
• Determine possible control methods – Mobilize resources needed
• Move somewhere to control hemorrhage – OR
– IR
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Permissive Hypotension • Low volume resuscitation • Don’t want to “pop the clot” “Injection of a fluid that will increase blood pressure has dangers in itself… if the pressure is raised before the surgeon is ready to check any bleeding that might take place, blood that is sorely needed may be lost”
-Walter B. Cannon, 1918
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Cannon et al. JAMA 1918
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Permissive Hypotension • Shock is bad
• Failure to clear lactate or base deficit leads to – Acute lung injury
– Increased infectious complications
– Increased mortality
• In most people we want to correct shock
• Actively bleeding patients goal directed therapy is
NOT possible
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Claridge et al. J Trauma 2000
Data for Permissive Hypotension
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598 Patients with penetrating trauma Immediate! fluid before OR Delayed! Fluid in/after OR
• Data on arrival
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Data for Permissive Hypotension
Bickell et al. NEJM 1994
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• Data after resuscitation
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Data for Permissive Hypotension
Bickell et al. NEJM 1994
• Pre-hospital and ED fluid volume 2500ml vs 375ml • No difference in OR fluid volumes
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Data for Permissive Hypotension
Bickell et al. NEJM 1994
c
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Data for Permissive Hypotension
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Data for Permissive Hypotension
• No difference in mortality • Could not achieve resuscitation to SBP 70 • Patients will find a MAP for their current physiology
• Similar to Mattox study • “Cyclic hyper resuscitation”
Dutton et al. J Trauma 2002
Cyclic Hyper Resuscitation
26 Dutton et al. J Trauma 2002
Permissive Hypotension with TBI? • Few studies in humans—TBI patients excluded
• Several animal models suggest that low volume
resuscitation may still be appropriate – Crystalloid has potential to increase ICP more than MAP
– Cerebral autoregulation may be sufficient to tolerate transient lower BPs
• Lower MAP/SBP must be tolerated from neurologic
standpoint until hemorrhage is controlled
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Talmore et al. Anesth & Analg 1999 Bourguignon et al. Arch Surg 1998
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Ongoing Trial
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• Randomized at entry into OR to MAP 50 vs 65 • Low MAP group:
• Received less blood and fluids • Less postop coagulopathy • Improved survival curve
Morrison et al. J Trauma 2011
Summary Permissive Hypotension • With ACTIVE hemorrhage:
– Small volume fluid boluses (~250)
– Titrate to radial pulse or MAP ~50
• Debatable in head injured population
– Limit hypotension to 20-30 mins
– Use blood/FFP
– Move to somewhere to obtain hemorrhage control
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Target Coagulopathy
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Hess et al. J Trauma 2008
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Target Coagulopathy
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Acute Traumatic Coagulopathy
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Brohi et all. J Trauma 2003
Acute Traumatic Coagulopathy
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Coagulopathy Predicts Death
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Abnormal PT
Macleod et al. J Trauma 2003
Resuscitation Protocols
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Borgman et al. J Trauma 2007
Survivorship Bias
• Patients who die early never have a chance to
receive plasma
• Studies that exclude early deaths miss precisely the
patients who might benefit from plasma
• 80% hemorrhagic deaths occur in first 6 hours
• Transfusion ratios are constantly changing,
especially in first 6 hours
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Ho et al. Anesth 2012 Holcomb et al. JAMA Surg 2013
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What Are Trauma Centers Doing?
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PROMMTT Study • 905 patients at 10 level I trauma centers
• Patients who received > 3 units PRBCs in first 24 hours
• In hospital mortality
• Findings: – Ratios not constant over 24hrs
– Early mortality (6hrs) decreased with ratios closer to 1:1
– After 24 hours transfusion ratios not associated with mortality
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Holcomb et al. JAMA Surg 2013 Del Junco et al. J Trauma 2013
PROPPR Trial
39 Cotton et al. JAMA 2015
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Target Coagulopathy • Resuscitating with blood products early in bleeding
patients improves outcomes
• Other ways to treat coagulopathy? – Tranexamic acid (TXA)
– Concentrated factors • PCCs
• Cryoprecipitate
• Fibrinogen
– Thromboelastography guided
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Tranexamic Acid
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CRASH-2 Trial
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Lancet 2010
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CRASH-2 Trial • >20,000 patients
• Trauma patients with or at risk of bleeding
• Treated within 8 hours
• 1 gram bolus followed by 1gm over 8 hrs
• All cause mortality reduction of 1.5% – Only death from bleeding affected
– Benefit most apparent in severe shock group and when given within 1 hr
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CRASH-2 Limitations
44 Napolitano et al. J Trauma 2012
MATTERs trials • Retrospective analysis of TXA (and cryo) use in US
military population • Both trials demonstrated lower mortality in those
treated with TXA (+/- cryo) compared to those not treated
• Limitations: – Retrospective – Not standardized indications or doses – No data regarding timing
• Incorporated into guidelines for combat casualty care
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Pre-hospital TXA (PATCH Study)
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STAAMP Trial
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Prothrombin Complex Concentrate • 3 factor and 4 factor products
– Inactivated Factor II, (VII), IX, X
• 25x higher factor content than FFP – 1 dose equivalent to 8-16u FFP
• Dramatically less volume than FFP
• Contain no fibrinogen
• FDA approved in hemophilia and life threatening
bleeding in patients on VKAs
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Cryoprecipitate • PROMMTT trial evaluated use of cryo in trauma
– Use varied from 7-82% among trauma centers
– No association with mortality
– Even in death from hemorrhage (<6hrs) most did not receive cryo (28% received)
• Hyperfibrinolysis well documented in ATC – Hyperfibrinolysis associated with high mortality
– Enthusiasm for early use of cryo and/or fibrinogen concentrates
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Levrat et al. B J Anesth 2008 Pommerening et al. JACS 2014
CRYOSTAT Trial
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Guided Targeting of Coagulopathy • TEG and ROTEM • Clot formation, propagation, stabilization, and
dissolution • Guide resuscitation
• Point of care test
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Thromboelastography
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McCoy et al. Clin Lab Med 2014
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Thromboelastography in Trauma
Da Luz et al. Crit Care 2014
Summary Target Coagulopathy • Aim for 1:1 (you probably won’t achieve it)
– Consider plasma first
• Consider TXA if significant bleeding suspected – Give TXA if in hem shock and < 3hrs from injury
• Consider PCCs in patients on VKAs with life threatening bleeding – Administer PCC if sig ICH with VKAs
– POC thromboelastography has potential to guide specific targeted resuscitation
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Damage Control Resuscitation • Early hemorrhage control
– OR – IR
• Permissive hypotension – Minimize crystalloid (dilution)
• Target early coagulopathy
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Questions?
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