John B. Holcomb, MD, FACS Professor and Vice Chair of Surgery
University of Texas Health Science Center, Houston, TX 1 Damage
Control Resuscitation
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Nothing to Disclose 2
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Texas Trauma Institute Houston, TX 3
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Memorial Hermann-TMC and UT Health Trauma Volume - 2012 Update
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In 2010, there were 5.1 million deaths from injuries 10% of all
deaths and the total number of deaths from injuries was greater
than the number from infection with HIV, tuberculosis, and malaria
combined (3.8 million). Overall, the number of deaths from injuries
increased by 24% between 1990 and 2010. 5 May 2, 2013
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Years of Potential Life Lost (YPLL) Before Age 65 Cause of
Death YPLL Percent All Causes 948,426 100.0% Unintentional Injury
199,903 21.1% Suicide 52,265 5.5% Homicide 48,190 5.1% Malignant
Neoplasms 137,221 14.5% Heart Disease 107,009 11.3% Perinatal
Period 75,496 8.0% Congenital Anomalies 43,615 4.6% Cerebrovascular
21,817 2.3% HIV 21,508 2.3% Liver Disease 21,352 2.3% All Others
220,050 23.2% The National Center for Injury Prevention and
Control. Web-based Injury Statistics Query and Reporting System. US
Department of Health and Human Services, CDC; 2008. Available at:
http://www.cdc.gov/ncipc/wisqars/. Accessed May 22,
2009.http://www.cdc.gov/ncipc/wisqars/ 31.7% 6
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UTHSC-Houston 1999-2008 Trauma admissions = 36,028 and 2394
deaths = 6.6% Early deaths ( 24 hrs) = 1398 or 58% 7 Deaths from
day 31-171 = 68/2394 = 3% 30 days = 97%
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8 J Trauma 2012 2001 - 2011, 4,596 battlefield fatalities were
reviewed 87% (n = 4012) of all injury mortality occurred pre-MTF
24% (n = 976) were deemed potentially survivable (PS) 91% (n = 888)
died from hemorrhage
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Bottom Line Up Front Crystalloid resuscitation increase blood
loss, transfusion requirements and death Balanced blood product
resuscitation decreases blood loss, transfusion requirements and
improves survival Must have thawed/liquid plasma in the ED to
really do this well Time is critical 9
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How to Resuscitate? Its not just raise the BP Not just the hole
in the blood vessel that needs rapid suture Why do we give RBCs
first? Red stuff Reverse the systemic and iatrogenic endothelial
injury Reverse permeability Prevent edema Repair the endothelium
Dampen the systemic inflammatory response Prevent and Reverse
coagulopathy Time is important 10
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11 Rapid progress in trauma care occurs during a war. Damage
control resuscitation addresses diagnosis and treatment of the
entire lethal triad immediately upon admission. J Trauma,
2007.
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DCR components Stop bleeding Hypotensive resuscitation Minimize
crystalloid Use thawed plasma to resuscitate patients Increased
platelet use Reverse hypothermia and acidosis Hemostatic adjuncts
12
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13 J Trauma 2012
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Typical 24 hour Resuscitation THEN 20 liters of LR 15 RBCs 5
FFP 0 platelets 14 Associated with decreased edema, MOF and
improved survival NOW 3-5 liters of LR 7 RBCs 6 FFP 1
platelets
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17 yr, GSW Liver, 60/30, BD-17 11 RBC 10 FFP 2 platelet 3
liters crystalloid 3 ops Home in 8 days 2010
Plasma and Platelets for everyone? Dzik WH. Predicting
hemorrhage using preoperative coagulation screening assays. Curr
Hematol Rep. 2004. Gajic O, Dzik WH, Toy P. Fresh frozen plasma and
platelet transfusion for nonbleeding patients in the intensive care
unit: benefit or harm? Crit Care Med. 2006. Abdel-Wahab OI, Healy
B, Dzik WH. Effect of fresh-frozen plasma transfusion on PT and
bleeding in patients with mild coagulation abnormalities.
Transfusion. 2006. 22
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23 2003-2004, n = 252 P < 0.05 162 53 16231 J Trauma,
2007
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Multicenter (16) Retrospective Massive Transfusion Study 12
months data collection 30,000 admissions and 11,650 transfused 466
MTs 24 Ann Surg 2008