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Haemostatic Resuscitation

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Haemostatic Resuscitation

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Haemostatic Resuscitation

  1. 1. Haemostatic resuscitation DR. FONSEKA SCGH – ED 2018
  2. 2.  Vital Part of Damage control resuscitation in Haemorrhagic shock 1] Permissive Hypotension[Minimal Normotension] 2] Haemostatic Resuscitation [ Massive Transfusion Protocol] 3] Anatomical Haemorrhage control [ Damage control surgery ]
  3. 3. Hemostatic resuscitation –  process of restoring and sustaining normal tissue perfusion in uncontrolled hemorrhagic shock, with preservation of effective clotting  until definitive anatomic control of hemorrhage is achieved, typically through surgery or angiographic embolization  Continued processes in a Patient with severe trauma
  4. 4. Major causes of death in trauma  Traumatic Brain injury- Common –Determined at the time of injury  Haemorrhage 40%- common and preventable contributing causes for Shock in trauma -Obstructive [tension pneumothorax and cardiac tamponade] -Distributive shock [High spinal cord injury] -Cardiac contusions/dysfunction
  5. 5. Injury associated Coagulopathy 1]Lethal Triad  Coagulopathy-Dilutional-Fluids or unbalanced blood products , DIC  Hypothermia- Exposure and Fluid administration  Acidosis- Tissue injury and shock 2]Acute Traumatic Coagulopathy 3]Microparticle release and platelet dysfunction 4]Ongoing losses
  6. 6. Acute Traumatic coagulopathy  impairment of hemostasis and activation of fibrinolysis that occurs early after injury  in the absence of thrombocytopenia and hypofibrinogenemia  biochemically evident prior to, and independent of, the development of significant acidosis, hypothermia, or hemodilution  INR > 1.5  Thought secondary to significant activation of protein C Inactivates Va and Viiia –Inhibiting X and Thrombin  4 fold increase in mortality  1-4 pts in every 10 patients with major trauma
  7. 7. Lethal triad  Coagulopathy – ATC , 10% reduction in clotting factors for every 500ml blood loss replaced by crystalloids/PRBC, DIC  Acidosis – markedly reduce activity of V11 , Xa and Va  Hypothermia - massive bleeding in conjunction with a core temperature of <30°C is rarely survived . Secondary to platelet dysfunction –starts < 34 °C and reduce CF function
  8. 8. Approach …
  9. 9. Guiding principles for resuscitation  Resuscitation using IV fluids -only for hypotensive patients, only until blood is available – To minimal Normotension  Blood products -as soon as the need for transfusion is recognized  Blood products should be given in equivalent amounts  Thromboelastometry- rapid point-of-care assessment of coagulation used to guide trauma resuscitation  Anatomical control of bleeding
  10. 10. PROMMTT study-2013-US  Prospective Observational multicentre major Trauma Study  n=1245  showed clear mortality benefit in 1st 24 hrs with blood product use in 1:1:1 ratios
  11. 11. PROPPR[RCT 2015]  680 severely injured pts  24- hour and 30-day mortality rates following trauma with severe bleeding were not different when FFP, platelets and RBCs were transfused in a 1:1:1 or 1:1:2 ratio  both groups similar complications rates were reported  However, in the 1:1:1 ratio group the PROPPR investigators found a reduced number of fatalities due to exsanguination
  12. 12. Massive transfusion protocol[MTP]  When to activate 1.Anticipated severe haemorrhage from history before patient arrival 2.Code Red : When USS not available or History from Ambulance Crew Systolic blood pressure <90 hgmm Unresponsive to one fluid bolus Suspected or confirmed massive haemorrhage 3.ABC score [Assessment of blood consumption Score] – 2 or more points ●Penetrating mechanism of injury ●Positive FAST (Focused Assessment with Sonography in Trauma) examination ●SBP of 90 mmHg or less ●Heart rate of 120 beats per minute (bpm) or greater
  13. 13. MTP  Predefined and balanced transfusion products  Aim to prevent coagulopathy while increasing O2 carrying capacity  Data from war zones in Iraq and Afghanistan replacement of >1 blood volume in 24 hours or >50% of blood volume in 4 hours
  14. 14. MTP-SCGH  4 units RBC  2 units FFP  1 adult therapeutic dose platelet  10 units cryoprecipitate if fibrinogen < 1.5 g/L
  15. 15. Antifibrinolytic agents- Tranexamic Acid  Recommended within first 3 hours of Trauma  CRASH2 Trial –RCT 2010 – Mortality benefit [Mortality 4.9% Vs 5.4%]  May increase bleeding if given in > 3 hours of trauma  1 g IV over 10 minutes and continue 1g/8 hours  No Thromboembolic events
  16. 16. Do not forget calcium  Calcium citrate – Lowers ionised Ca  Citrate overload from Blood products- inevitable consequence of receiving massive transfusion  3mg in 1 unit PRBC  Usually rapidly cleared by liver – Impaired in trauma pt.  Normal iCa - 1.15-1.33 mmol/L  Below < 1.1 mmol/L long QT, dysrhythmias negative inotropy and vasoplegia, hypotension hypocoagulability  Predicts Hospital Mortality
  17. 17. Calcium  Measure every 15-30 minutes while resuscitating  If iCa < 1mmol/L –replace with calcium chloride 1 g or 2 -3 g of calcium gluconate
  18. 18. Parameters Values to aim for Temperature >35 °C Acid-base status ph >7.2, base excess <–6, lactate <4 mmol/L Ionised calcium (Ca) >1.1 mmol/L Haemoglobin (Hb) This should not be used alone as transfusion trigger; and, should be interpreted in context with hemodynamic status, organ & tissue perfusion. Platelet (Plt) >50 x 10 9 /L PT/APTT <1.5x of normal INR ≤ 1.5 Fibrinogen >1.0 g/L
  19. 19.  Patients on Anticoagulants ………
  20. 20. Reversing Anticoagulants  A specific reversal agent/antidote  DDAVP  Drug removal from the circulation and/or gastrointestinal tract  Prothrombotic - Prothrombin complex concentrates and other Blood products
  21. 21. FFP  Contains all coagulation factors  One unit is 200- 250 ml [ from I unit whole blood]  Dose 10-15 ml /Kg  Given Stat in haemorrhage  Stored at or below -25c  Thawed in 10-30 minutes  Expected to increase CFs by 2.5% to 10% per unit  If PT/APTT > 1.5 times the normal needs 2-8 units
  22. 22. Cryoprecipitate  Contains –Fibrinogen, Factors Viii,Xiii,vWF  Fibrinogen is the 1st CF to reach critical low levels  I unit is 10-20 ml  Comes in premade pools [ 1 to 5 units in one pool]  Dose 5- 10 units [ 50-200 ml]- may be 5 units / 5 kg BW in massive Trauma haemorrhage  Stored at -25c or below . Thawed in 10-30 minutes
  23. 23. Fibrinogen Concentrate  Approved to use in pt. with congenital Fibrinogen deficiency  No benefit over Cryoprecipitate in Trauma
  24. 24. Direct Reversal of Anticoagulants  Dabigatran - Idarucizumab [2.5 g/50 mL (50 mL): $2100.00] - 2.5 g IV x 2 :15 minutes apart – repeat once - Haemodialysis -PCC not recommended –used if antidote unavailable -FFP and other blood products can be given as a Part of MTP  Warfarin - Vit K 5-10 mg IV [ takes 6-12 hours] -PCC [ recommended 4 factors with factor Vll] - FFP with 3 Factor concentrate
  25. 25.  direct factor Xa inhibitors - No antidote - Can not be dialysed - PCC and FFP Reversal agents Under Development  Andexanet alfa – For Xa inhibitors and LMWH reversal  Ciraparantag- For Xa inhibitors, Direct Thrombin Inhibitors and LMWH
  26. 26. Prothrombinex – 3 factor combination  provision of factors II, IX and X  Available in Australia-Prothrombinex -VF  Dosing is based on units of factor IX activity  Correct INR with in 30 minutes  30- 50 IU/ kg given IV
  27. 27. Protamine  Reversal of Heparin  Heparin inactivates Thrombin and Xa  1mg / 100 units of Heparin [ 25-50 mg IV ]  For Enoxaparin given within 8 hours 1 mg / 1mg Given > 8 hours ago 0.5mg/1mg  SE -anaphylaxis in individuals who have previously been exposed to protamine [ DM , Fish allergy]
  28. 28. rFVII concentrate  Off – label use in Traumatic Haemorrhage  Only approved for Haemophilia and Platelet functional disorder associated bleeding  Available research – No mortality benefit - May reduce amount of transfusions - May increase Thromboembolic risk  shows significant potential and appears to be safe in young, previously healthy individuals with traumatic haemorrhage
  29. 29.  Desmopressin (DDAVP) -Synthetic analogue of ADH -Increase release of Factor Vlll and vWF from platelets and endothelial cells -Used mostly for intra-op microvascular bleeding in vWF deficiency or suspected platelet dysfunction in uraemia
  30. 30. Anatomical Control of bleeding  Internal bleeding – manage as appropriate – OT -damage control surgery/ Angiographic embolization Pelvic binder Reduce and splint long bone fractures Cross clamp aorta IABP  External bleeding Direct Pressure Staples to scalp wounds Tourniquet Ligate vessels Folly catheter
  31. 31. Damage controlled surgery Aims -Arrest bleeding -Limit contamination -Maintain blood floor to organs and extremities -Continue resuscitation in ICU -Delayed definitive surgical management once patient is stable
  32. 32. What if TBI or SCI in the same patient?  Minimal Normotention [ 70-90 hgmm SBP . MAP 50-65 hgmm . Mentation , Radial pulse ]?  Controversial  Some resuscitates to above  Some recommend MAP 85-90 hgmm  Therefore should be individualised  Maintain haemostasis  Vasopressors may be needed in refractory Neurogenic shock once haemorrhagic shock is excluded or treated to the best possible level
  33. 33. Monitor Progress on Haemostasis? Time Critical assessments …  Clinical assessment and HR , BP , Pulseoxymetry , GCS, UOP  ROTEM  Base excess, Lactate , iCa , Hb
  34. 34. Is it Really Working ? Activation of Coagulation and inflammation of trauma study  Prospective cohort study – 2014 International Trauma Research Network  106 pts. receiving MTP- Trauma centres UK and Norway  ROTEM and Lactate measurements  Shows No improvement of lactate and showed worsening of Coagulopathy But – -High Ratios RBC:FFP:Platelets were not achieved until late in resuscitation -Crystalloids were administered -PROMMTT study 2013 n=1245 showed clear mortality benefit in 1st 24 hrs with 1:1:1 ratios
  35. 35. Rotational Thromboelastometry
  36. 36.  Shows limited abnormalities of initial phase of coagulation  Main use is monitoring Heparin, warfarin and haemophilia  Takes 40-45 minutes Coagulation Profile….
  37. 37. ROTEM…  information within 5 minutes  Real-time measurements using whole blood  guide coagulation therapy according to actual needs  Reduced transfusion requirements  Reduced transfusion related adverse events  Improved outcomes  Used in various clinical settings – liver transplant, cardiac surgery, obstetrics & trauma  High negative predictive value –If normal results -bleeding highly unlikely due to significant coagulopathy  Provide information in overall haemostasis even one component is lacking – Low platelets compensated by high Fibrinogen  Lacks data on effects of DOACs
  38. 38. PT INR aPTT II,VII,IX,X EXTEM INTEM FIBTEM HEPTEM Primary pathway V, Platelet, Ca Viii, plat, ca Dabigatran RIVEROXABAN
  39. 39. Time from onset of clotting to 20mm amplitude Alpha < measure rapidity of fibrin buil up and cross link 20mm 90mm
  40. 40. SCGH- MTP & ROTEM Algorithm for Critical Bleeding&  http://scghed.com/wp-content/uploads/2017/05/Massive-Transfusion-Protocol-2017.pdf
  41. 41. Summary …  Early recognition and appropriate resuscitation  Varies according to individual and injuries  Involve all relevant specialities early-Early definitive Mx of haemorrhage  Damage control resuscitation  Use ROTEM/ continue to monitor – Clinical, BA, Lactate, Ca  Tranexamic acid < 3 hours  Modifications in-Head injury , Spinal injury  Complications of MT
  42. 42.  Thank you !

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