Trauma & Damage Control Resuscitation

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Presentation Description

an update on what is new and future in damage control / prehospital and ED management and resuscitation of trauma

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Trauma & Damage Control Resuscitation: what’s new?:

Trauma & Damage C ontrol R esuscitation: what’s new? Dr. Habib Md Reazaul Karim MBBS, MD, DNB, IDCCM Critical Care, Emergency & Perioperative Physician

Background & Objective:

Background & Objective Optimal management of hypotensive trauma patients- still under investigation Method of fluid delivery & the type of fluid used is still not clear Damage control resuscitation …. Present teaching-learning session is aimed to discuss these issue with current & recent knowledge

Trauma resuscitation :

Trauma resuscitation Hemorrhage- the most common cause of preventable death in trauma optimal fluid resuscitation regimen – debate is on More recently- Damage Control Resuscitation (DCR) has received more attention permissive hypotension- aka- controlled resuscitation is part of a broader strategy- DCR

DCR: Focus:

DCR: Focus Stopping hemorrhage Replacing fluids lost Correcting the lethal triad of coagulopathy, acidosis, and hypothermia

Permissive hypotension :

Permissive hypotension Designed to resuscitate a traumatically injured patient through balanced fluid resuscitation Aimed at preventing acidosis, hypothermia, and multi-organ dysfunction. applies to the hypovolemic trauma patient doesn’t include traumatic head injury or spinal cord injury

Balanced fluid resuscitation:

Balanced fluid resuscitation involves correcting coagulopathies with blood components surgically controlling the source of bleeding administering normal saline or lactated Ringers solutions cautiously to prevent hemodilution

Goals of resuscitation:

Goals of resuscitation Stop hemorrhage Resuscitate Replace lost volume Replace blood components Maintain energy production Maintain oxygen delivery to RBC/Hb molecule Deliver RBCs/oxygen to tissues

“don’t pop the clot”:

“don’t pop the clot”

Pre-hospital Resuscitation: New concept:

Pre-hospital Resuscitation: New concept Stop Visible bleeding No IV fluids necessary if patient is not in shock If in shock 250 – 500 cc crystalloid bolus (en route) Reassess Repeat bolus if necessary Target BP -

ED Resuscitation: New Concept:

ED Resuscitation: New Concept “ Replace what is lost” Limited use of crystalloid for trauma Early administration of blood “1:1:1” – 1 unit PRBCs : 1 unit FFP : 1 unit platelets Or 1 PRBC : 1 FFP (if platelets not available)

Current Guidelines (EAST-2009):

Current Guidelines (EAST-2009) Blunt / penetrating trauma: Insufficient data to suggest benefit from prehospital fluid resuscitation. Penetrating injuries & transport times < 30 minutes: Withheld fluids in the prehospital setting in alert patients or having a palpable radial pulse. Fluids (in the form of small boluses, i.e., 250 mL) Target: coherent mental status or palpable radial pulse TBI: Fluids titrated to SBP >90 mmHg OR mean >60 mmHg

Current Guidelines:

Current Guidelines Recommend limiting initial resuscitation to 1 liter of crystalloid from previous 2L No blood pressure goals (Advanced Trauma Life Support Student Course Manual  9th ed. Chicago, IL: American College of Surgeons, 2012)

Current Guidelines: European consensus :

Current Guidelines: European consensus Recommend Target SBPof 80 to 100 mmHg until major bleeding has been stopped in the initial phase following trauma without brain injury (Grade 1C). Controlled hypotensive fluid resuscitation should aim to achieve a mean arterial pressure of 65 mmHg or more. (Rossaint R, et al. Management of bleeding following major trauma: an updated European guideline.  Critical Care,  2010; 14: R52)

Recent Literature:

Recent Literature The principles of DCR hemorrhage control careful use of crystalloid early delivery of high ratios of platelets and plasma to red blood cells. Early recognition of at-risk patients in order to avoid the onset of the ‘lethal triad’ A balanced ratio of blood products, ideally 1:1:1 ratio should be a goal in early resuscitation ( DOI: 10.1016/j.ijsu.2016.03.064 (Int J Surg Update 2016)

Trauma resuscitation : is 1:1:1 the answer?:

Trauma resuscitation : is 1:1:1 the answer? Plasma, red blood cell and platelet ratios of 1:1:1 appear to be the best substitution for fresh whole blood However, the current literature consists only of survivor bias-prone observational studies (Miller Perioperative Medicine 2013, 2:13)

PROPPR study:

PROPPR study Pragmatic Randomized Optimal Platelet and Plasma Ratios (PROPPR) trial Plasma–Platelet–Red blood cell in a ratio of 1:1:1, results in improved survival at 3 hours and a reduction in deaths caused by exsanguinations in the first 24 hours compared with a 1:1:2 ratio a significant survival difference at 24 hours or 30 days was not demonstrated (JAMA. 2015;313:471–482)

DCR & Emergency laparotomy:

DCR & Emergency laparotomy No evidence that resuscitation strategy affects whether a patient requires an emergency laparotomy, time to laparotomy, or subsequent survival. (J Trauma Acute Care Surg. 2016;80: 568–575)

Future:

Future Lyophilized plasma for prehospital use Coagulation factor concentrate-based therapy for remote damage control resuscitation (RDCR) (Transfusion 2016;56(Suppl 2):S149-S156)

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