20131113 trauma christmas 2013

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20131113 trauma christmas 2013

  1. 1. TRAUMA Holger Baumann MD vooruitstrevend in perioperatieve zorg afdeling Anesthesiologie
  2. 2. WHY TRAUMA? Number 1 Killer 40 % uncontrolled hemorrhage 25 % coagulopathic in the ED Krug, Am J Public Health 2000 Sauaia, J Trauma 1995 Brohi, J Trauma 2003 Maegele Shock 2006
  3. 3. Trauma & Coagulopathy Brohi, Curr Opp Crit Care 2007 Frith, J Thromb 2010
  4. 4. 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 2013 www.advancedbleedingcare.org
  5. 5. STOP The Bleeding Campaign Screen: Scores Labor Treat: FFP Fibrinogeen TRX PCC rFVIIa Observe: PT aPTT ROTEM/TEG Prevent: Preconditions
  6. 6. Screen for risk of bleeding/coagulopathy SCORES: SCORES: ABC TASH Penetrating mechanism ED SBP <90 mm ED HR >120/min Positive FAST Nunez, J Trauma 2009 Cotton J Trauma 2010 Krumrei J Trauma 2012 Yucsel J Trauma 2006
  7. 7. Trigger for MT OR for MT 24 INR>1,5 SBP < 90 mmHg Hb < 6,6 mml/l BD > 6,0 HR > 120 bpm Penetrating dFAST + OR MT 24 + hemorrhagic death OR MT 6 + hemorragic death 2,2 2,5 3,9 1,9 1,7 1,5 1,8 1,8 1,1 1,0 1,9 1,8 2,0 1,2 0,9 1,8 Modified from 2,0 3,0 1,2 1,2 1,9 Calcutt, J Trauma 2013 (PROMMT)
  8. 8. MTS ≥ 2 MT 24 MT 24 MT 6 + hemorrhagic death + 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 from Calcutt, J Trauma 2013 (PROMMTT)
  9. 9. Base Deficite 1C BD <= 2 Blood products TASH Score Mortality % Action? BD >2 6 BD >610 BD> 10 1,5 4,5 10,3 20,3 3,5 7,4 6,1 12 10,6 23 14,3 51,3 Act Prepare MTP Watch Consider modified Rec 11 Mutschler, Crit Care 2013
  10. 10. Shock Index ? BD≤2 SI < 0,6 BD>2-6,0 BD>6,0-10,0 BD<10,0 SI 0,6-1,0 SI 1,0-1,4 SI ≥ 1,4 BD≤2 SI < 0,6 BD>2-6,0 BD>6,0-10,0 BD<10,0 SI 0,6-1,0 SI 1,0-1,4 SI ≥ 1,4 modified Mutschler, Crit Care 8- 2013
  11. 11. Conventioneel Lab. vs POC Standard-Lab Point of Care (ROTEM/TEG) NO YES 30-60 min. 5-15 min. Hyperfibrinolyse NO YES Sterkte van stolsel NO YES Evaluatie voor bloeding Tijd tot uitslag
  12. 12. Conventioneel Lab. vs POC Standard-Lab Point of Care (ROTEM/TEG) NO YES 30-60 min. 5-15 min. Hyperfibrinolyse NO YES Sterkte van stolsel NO YES Evaluatie voor bloeding Tijd tot uitslag Logistics? Resources? Costs? QA? Training?
  13. 13. 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
  14. 14. Monitoring: ..routine practice include the measurement of INR, APTT, fibrinogen and platelets. INR and APTT alone should not be used to guide haemostatic therapy. 1C .. ..Thrombelastometry to assist in guiding haemostatic therapy. 2C modified Rec 12 Spahn, Crit Care 2013
  15. 15. Holcomb, Ann Surg 2012
  16. 16. FIB. - CRYO - FFP Fibrinogen Content Fib. FFP PCC constant inconsistent constan Time admission Immediately 30 min. Immediate
  17. 17. FFP’s – R24 Early treatment with thawed FFP in patients with massive bleeding. Initial dose is 10 to 15 ml/kg. 1B Spahn, Crit Care 2013
  18. 18. 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
  19. 19. PCC Emergency reversal of Vit. K-dependent oral anticoagulants. 1B ..PCC ..in the bleeding patient with thromboelastic evidence of delayed coagulaton ininiation. 1C Rec 31 Spahn, Crit Care 2013
  20. 20. Tranexminezuur (TRX)
  21. 21. Tranexminezuur (TRX) ..as early as possible to the bleeding patient 1A ..within 3 h after injury 1B Consider TRX en route to the hospital 1C Rec 31 Spahn, Crit Care 2013
  22. 22. Observe Response to Intervention • Clinical • ROTEM •
  23. 23. Prevent secondary coagulopathy • • • • Damage control Rewarming Restore physiology No delay
  24. 24. ‘De drie eenheid’
  25. 25. Whole blood Bloedprodukten Hemodilutie - – 1:1:1 approach 650 ml koud spul Hb 5.5 mmol/l (8.9 g/dl) Thr. 75 * 109 Plasma factors 70 % Fibrinogen: 0,5 -1 g (?) 500 mL Warm Hct: 38-50% Plt: 150-400K Coags: 100% 1500 mg Fibrinogen Armand, Transf Medicine Reviews 2003 Como, Transfusion 2004
  26. 26. Massaal bloedtransfusie protocol @
  27. 27. How do u sweet’n your coffee?
  28. 28. rFVIIa in Trauma Consider rFVIIa after “conventional” therapy, if pH > 7,2 Temp. > 35,0C Fibrinogen > 100 mg/dl or FIBTEM >12 mm Thrombocytes > 50/nl or Extem > 45mm Hyperfibrinolysis ruled out/therapy No surgical/IR therapy rFVIIa(Novoseven): 90micg/kg BW 2C REC 33: Spahn, Crit Care 2013
  29. 29. A failure in planning is a plan for failure S03E08 Star Wars The Clone Wars Zorg voor heldere lokale protocollen. Multidisciplinaire aanpak Voorlichting en training Behandel coagulopathieën • • • • • Basale behandeling TRX FFP/FIB MTP rFVIIa
  30. 30. En nu?
  31. 31. 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). Enoughin perioperatieve zorg vooruitstrevend to give > 1 g/l afdeling Anesthesiologie
  32. 32. Recommendation RBC’s ATIII Hb 4,4-5,6 mmol/l No 1C 1C 17 26 DDAVP Not routinely 2C 30 > 50000 Platelets > 100000 in TBI 1C 2C 28 Calcium ≥ 1,0 mmol/l 1C 25

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