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Prof Karim Brohi Major haemorrhage & Coagulopathy

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Rahul Goswami
Rahul Goswami

Prof Karim Brohi at the trauma track of SEMS 2014

Health & Medicine
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MAJOR HAEMORRHAGE & TRAUMA-INDUCED COAGULOPATHY KARIM BROHI, FRCS FRCA Professor of Trauma Sciences, QMUL Centre for Trauma Sciences Queen Mary University of London www.c4ts.qmul.ac.uk Royal London Major Trauma Centre Barts Health NHS Trust
43%
DIED OF WOUNDS 506 US COMBAT CASUALTIES 2001-2011
DIED OF WOUNDS 506 KILLED IN ACTION 4090 PREVENTABLE 1075 HEMORRHAGE 92% US COMBAT CASUALTIES 2001-2011
HAEMOSTATIC Resuscitation 1. Early haemorrhage control 2. Permissive hypotension 3. Limit fluid infusions (dilution) 4. Target coagulopathy
HAEMOSTATIC Resuscitation 1. Early haemorrhage control 2. Permissive hypotension 3. Limit fluid infusions (dilution) 4. Target coagulopathy
HAEMOSTATIC Resuscitation 1. Early haemorrhage control (DCS) 2. Permissive hypotension 3. Limit fluid infusions (dilution) 4. Target coagulopathy
Trauma Hemorrhage Genetics Shock Fibrinolysis Inflammation Hypothermia Acidemia Loss, Dilution ATC TRAUMA-INDUCED COAGULOPATHY (TIC)
Trauma Hemorrhage Shock ATC TRAUMA-INDUCED COAGULOPATHY (TIC)
Acute Traumatic Coagulopathy ATC
Trauma Hemorrhage Shock ATC TRAUMA-INDUCED COAGULOPATHY (TIC)
Trauma Hemorrhage Genetics Shock Fibrinolysis Inflammation Hypothermia Acidemia Loss, Dilution ATC TRAUMA-INDUCED COAGULOPATHY (TIC)
100 80 60 40 20 0 -20 -40 -60 -80 -100 exTEM PTr Comparison 0 10 20 30 40 50 60 Firmness [mm] Time [min] EXTEM PTR<1.2 EXTEM PTR>1.2
ATC: CA5 < 36mm
?
FIBRINOGEN LOSS
CRYOSTAT
CRYOSTAT Mortality a Standard: Y 7/22 : 32% Early CRYO: 3/21 : 14%
FIBRINOLYSIS
60% 40% 20% 0% Normal Occult Severe Occult Overt % of Patients Hyperfibrinolysis
Mechanism of ATC
Systemic Activation of Protein C
Activated Protein C (ng/ml)
VIIa IXa Xa + + + + XIIa XIa Thrombin Fibrin TM TM TM TM + platelet Thrombin-TM Fibrinogen
VIIa IXa Xa + XIIa XIa aPC - PC Thrombin-TM - Thrombin Fibrin + platelet TM TM TM TM Fibrinogen
VIIa IXa Xa + XIIa XIa aPC - PC Thrombin-TM - Thrombin Fibrin + platelet TM TM TM TM Fibrinogen
VIIa IXa Xa + XIIa XIa aPC - PC Thrombin-TM - FDPs Plasmin Fibrinogen tPA + Thrombin Fibrin + platelet +
VIIa IXa Xa + XIIa XIa aPC - PC Thrombin-TM - FDPs Plasmin Fibrinogen tPA + Thrombin Fibrin + platelet + -
VIIa IXa Xa + XIIa XIa Fibrinogen Thrombin Fibrin aPC - PC Thrombin-TM - FDPs Plasmin PAI-1 tPA + - - + platelet + -
HAEMOSTATIC Resuscitation 1. Early haemorrhage control 2. Permissive hypotension 3. Limit fluid infusions (dilution) 4. Target coagulopathy
Prof Karim Brohi Major haemorrhage & Coagulopathy

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Prof Karim Brohi Major haemorrhage & Coagulopathy

  • 1. MAJOR HAEMORRHAGE & TRAUMA-INDUCED COAGULOPATHY KARIM BROHI, FRCS FRCA Professor of Trauma Sciences, QMUL Centre for Trauma Sciences Queen Mary University of London www.c4ts.qmul.ac.uk Royal London Major Trauma Centre Barts Health NHS Trust
  • 2.
  • 3.
  • 4.
  • 5.
  • 6. 43%
  • 7. DIED OF WOUNDS 506 US COMBAT CASUALTIES 2001-2011
  • 8. DIED OF WOUNDS 506 KILLED IN ACTION 4090 PREVENTABLE 1075 HEMORRHAGE 92% US COMBAT CASUALTIES 2001-2011
  • 9.
  • 10.
  • 11. HAEMOSTATIC Resuscitation 1. Early haemorrhage control 2. Permissive hypotension 3. Limit fluid infusions (dilution) 4. Target coagulopathy
  • 12. HAEMOSTATIC Resuscitation 1. Early haemorrhage control 2. Permissive hypotension 3. Limit fluid infusions (dilution) 4. Target coagulopathy
  • 13.
  • 14.
  • 15.
  • 16.
  • 17.
  • 18. HAEMOSTATIC Resuscitation 1. Early haemorrhage control (DCS) 2. Permissive hypotension 3. Limit fluid infusions (dilution) 4. Target coagulopathy
  • 19. Trauma Hemorrhage Genetics Shock Fibrinolysis Inflammation Hypothermia Acidemia Loss, Dilution ATC TRAUMA-INDUCED COAGULOPATHY (TIC)
  • 20. Trauma Hemorrhage Shock ATC TRAUMA-INDUCED COAGULOPATHY (TIC)
  • 22.
  • 23.
  • 24.
  • 25.
  • 26.
  • 27.
  • 28.
  • 29. Trauma Hemorrhage Shock ATC TRAUMA-INDUCED COAGULOPATHY (TIC)
  • 30. Trauma Hemorrhage Genetics Shock Fibrinolysis Inflammation Hypothermia Acidemia Loss, Dilution ATC TRAUMA-INDUCED COAGULOPATHY (TIC)
  • 31.
  • 32.
  • 33.
  • 34.
  • 35.
  • 36.
  • 37.
  • 38.
  • 39.
  • 40.
  • 41.
  • 42.
  • 43.
  • 44.
  • 45.
  • 46. 100 80 60 40 20 0 -20 -40 -60 -80 -100 exTEM PTr Comparison 0 10 20 30 40 50 60 Firmness [mm] Time [min] EXTEM PTR<1.2 EXTEM PTR>1.2
  • 47. ATC: CA5 < 36mm
  • 48.
  • 49.
  • 50.
  • 51.
  • 52. ?
  • 53.
  • 54.
  • 55.
  • 56.
  • 58.
  • 59.
  • 61. CRYOSTAT Mortality a Standard: Y 7/22 : 32% Early CRYO: 3/21 : 14%
  • 63.
  • 64.
  • 65. 60% 40% 20% 0% Normal Occult Severe Occult Overt % of Patients Hyperfibrinolysis
  • 69.
  • 70. VIIa IXa Xa + + + + XIIa XIa Thrombin Fibrin TM TM TM TM + platelet Thrombin-TM Fibrinogen
  • 71. VIIa IXa Xa + XIIa XIa aPC - PC Thrombin-TM - Thrombin Fibrin + platelet TM TM TM TM Fibrinogen
  • 72. VIIa IXa Xa + XIIa XIa aPC - PC Thrombin-TM - Thrombin Fibrin + platelet TM TM TM TM Fibrinogen
  • 73. VIIa IXa Xa + XIIa XIa aPC - PC Thrombin-TM - FDPs Plasmin Fibrinogen tPA + Thrombin Fibrin + platelet +
  • 74. VIIa IXa Xa + XIIa XIa aPC - PC Thrombin-TM - FDPs Plasmin Fibrinogen tPA + Thrombin Fibrin + platelet + -
  • 75. VIIa IXa Xa + XIIa XIa Fibrinogen Thrombin Fibrin aPC - PC Thrombin-TM - FDPs Plasmin PAI-1 tPA + - - + platelet + -
  • 76.
  • 77.
  • 78.
  • 79. HAEMOSTATIC Resuscitation 1. Early haemorrhage control 2. Permissive hypotension 3. Limit fluid infusions (dilution) 4. Target coagulopathy

Editor's Notes

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