Damage Control Resuscitation

Dr Adam Chesters
Specialist Registrar in Pre-Hospital Care
Essex and Herts Air Ambulance

Objectives

Describe the coagulopathy of trauma shock

Define massive transfusion
Predict those patients likely to require MT
Outline new strategies in trauma resuscitation

The lethal triad

The lethal triad

Acute coagulopathy
Consumption and loss of clotting factors
Dilution (fluid resuscitation, autoresuscitation)
Clotting factor dysfunction (hypothermia, acidosis)

Hypothermia
Exposure
Cold fluids

Acidosis
Hypoperfusion from shock
Anaerobic metabolism and lactate production

What does this all mean for us?

Up to 25% of trauma patients have
established coagulopathy on arrival at the ED
A core temperature <35o on admission to the
ED increases mortality (odds ratio: 1.5)
Pre-hospital treatments target the triad:
Temperature control
Not making coagulopathy worse
Good pre-alert to receiving hospital (code red)

Massive transfusion

Loss of one blood volume within 24 hours

Loss of 50% of blood volume within 3 hours
Rate of blood loss over 150 mls/hr

Normal blood volume is 7% of ideal weight

70kg man approx 6 litres

Can we predict the need for MT?

Several tools proposed
Not validated for ED or pre-hospital use
Trauma Associated Severe Haemorrhage (TASH) Score:

Male
Unstable pelvic fracture
Open or deformed femur fracture
HR >120 bpm
SBP <100 mmHg
FAST positive for intra-abdominal fluid
Hb <11 g/dL
Base deficit > -2

Can we predict the need for MT?

McLaughlin 2008
HR >105 bpm
SBP <110 mmHg
Arterial blood pH <7.25
Haematocrit <32%

Screiber 2007
Penetrating injury
Hb <11 g/dL
INR >1.5

Bottom line
Difficult to predict need for MT in the field and
in the ED
Important to alert receiving unit if we think
our patient is bleeding code red
Blood products take time to prepare
0 negative PRC available immediately
Platelets and FFP at least 30 minutes to thaw

Strategies in trauma resuscitation

Permissive hypotension
Haemostatic resuscitation
Damage-control surgery
DAMAGE CONTROL RESUSCITATION

Permissive hypotension
ATLS teaching vs. BATLS and PHTLS (evidence-base?)
HEMS SOPs
ED management strategies depends on the personnel
Vietnam, Falklands and other war lessons
Penetrating vs blunt trauma
Controlled vs uncontrolled haemorrhage
The first clot is the best
Progressive traumatic coagulopathy
Earlier definitive control of bleeding
Concurrent severe head injury risk vs. benefit
Effects on mortality confounding issues?

Permissive hypotension
Bickell et al (1994)
70% vs 62% survival in penetrating torso injury
Immediate vs delayed resuscitation
Trend towards increased intra-operative blood loss
Major influence for BATLS and PHTLS
Animal models no resuscitation in uncontrolled bleeding
Early increased MAP disrupts thrombus
Dilutional coagulopathy
Using 3:1 rule taught in ATLS, all animals died
Permissive hypotension in uncontrolled bleeding
Moderately under-resuscitated animals do better
Delayed resuscitation allows clot to stabilise

Permissive hypotension - conclusions

Aggressive early fluid resuscitation in penetrating trauma with
uncontrolled bleeding may be dangerous
Early definitive surgical control of bleeding is best
There is no specific evidence to inform resuscitation strategies in
blunt trauma with uncontrolled bleeding
The evidence for maintaining CPP in head injuries is much stronger

ATLS provides a framework for those who are not experts in trauma

How the body clots

Bleeding is bad so the body tries to stop it
There are 3 phases:
Vascular phase
Vasospasm in direct response to vessel trauma

Platelet phase
Adherence to damaged vessels
Von Willebrand factor acts as an anchor
Platelet surface activates the coagulation cascade

Coagulation phase
Coagulation cascade

Haemostatic resuscitation
Early use of blood and blood products
PRC oxygenation and volume, not clotting
FFP coagulation phase, helps clotting
Platelets platelet phase, helps clotting

Use of adjunctive therapy

Factor VIIa
Tranexamic acid
Calcium

Massive transfusion common UK policy

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Restore circulating volume

Colloid or crystalloid
Stop bleeding
Laboratory investigations

FBC, PT, APTT, fibrinogen, cross-match

Repeat every 4 hours or after replacement of one third blood volume

Suitable red cells for ongoing bleeding or acute low Hb

O-negative, type-specific, fully cross-matched

Platelets

For counts of <50 (or <100 in major trauma)

FFP

Aim for APTT and PT <1.5 times above normal

4 units per dose for an adult (15mls/kg)

Cryoprecipitate

For fibrinogen <1

Watch for DIC

APTT/PT prolonged, low fibrinogen/platelets, high FDPs, bleeding

Consider the use of activated Factor VII in life-threatening uncontrolled bleeding

Blood and blood products

Previous MT policies based on laboratory tests
APTT, PT, Hb, fibrinogen
Resulted in PRC:other products of > 8:1

Military practice in the UK in Iraq 2

Clinical decision to initiate MT policy
PRC:FFP in a 1:1 ratio
Absolute mortality reduction of 46% (vs. 8:1)
Platelets in 1:1:1 ratio probably improves survival

Adjuncts to non-surgical haemostasis

Factor VIIa
5000 per dose
May reduce
transfusion
requirements in
blunt trauma
Last resort measure?
Studies ongoing....

Adjuncts to non-surgical haemostasis

Tranexamic acid
Prevents clot break up (fibrinolysis)
Reduces bleeding after elective surgery
No evidence of benefit in trauma

Calcium
Required at several stages of clotting cascade
Something to be sorted out in ITU

Damage control surgery

Patients with major trauma will not survive prolonged
definitive surgery
Stop haemorrhage
Temporary clamping
Packing the abdomen

Minimise contamination
Resection of diseased organs
Good wash out of big cavities

Go back and finish up another day

Leave the abdomen open, stick in drains
Optimise clotting and physiology on ITU

Summary
Most trauma patients have a clotting problem
We must address the lethal triad ASAP
Damage control resuscitation includes
permissive hypotension, haemostatic
resuscitation and damage control surgery
Early use of 1:1:1 ratios of PRC:FFP:platelets
Adjuncts can be used in the ED/ITU later
Long immediate operations are bad

Relevance for HEMS

Recognise haemorrhagic shock

Triage and pre-alert appropriately
Keep the patient warm
Permissive hypotension for penetrating trauma
Permissive hypotension for isolated blunt trauma?
Maintain cerebral perfusion pressure in head injuries