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
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
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. 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. 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. 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. 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
16. FIB. - CRYO - FFP
Fibrinogen
Content Fib.
FFP
PCC
constant
inconsistent
constan
Time admission Immediately 30 min.
Immediate
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. 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. 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
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
30. 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
31. 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
33. 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
