Debemos cambiar el paradigma! Para la reanimación del paciente politraumatizado en shock hemorrágico, debemos ser tremendamente cuidadosos y conservadores con el aporte de cristaloides o coloides!
Shock hemorrágico en el paciente politraumatizado, no debe tratarse con fisiológico, Ringer o gelatinas! Mientras más de estos productos reciban, peor pronóstico tiene nuestro paciente.
En este contexto, no debe administrarse nada que no aporte a transportar oxigeno o que colabore con la coagulación!
No más reanimación tipo ATLS, donde se recomendaba 2lt de suero fisiológico y solicitar exámenes para evaluar coagulación y ver necesidad de productos sanguíneos... NO MÁS!!!
Conceptos Claves:
- politraumatizado + shock = hemorrágico (abdomen, tórax, extremidades)
- control anatómico del sangrado es vital!
- no reanimar contra presión arterial, reanimar contra perfusión
- si necesita volumen; aportar fluidos que aporten a la coagulación o a transportar oxígeno
- recuerden calcio y ácido tranexámico
- hosp pequeño, o 1rio o 2ndario: esfuerzos en traslado
- hospital cuidado definitivo: protocolo transfusión masiva, hipotensión permisiva, cirugía control de daño, UCI
5. Evaluación Primaria
via aérea permeable, en linea media, sospecha CC
MP + simetrico, FR: 28 x’, SaO2: 93%, sin uso de
musculatura accesoria
PA: 70/40, FC: 138x’, sin hemorragia, frio a distal
E – FAST (-)
13. Conducta?
Buscar sitio de sangrado
Estable: puede ir a TAC
Inestable: FAST seriado, pabellón
Fijar pelvis
Apoyo con Rx
Iniciar reanimación con volumen
15. Old School
ATLS
Suero fisiológico o RL 2000 cc hasta PA normal
Si persiste hipotensión, pasar a GR
Plasma
Approach paciente especifico
Esperar el INR y corregir
16. Evidencia animal
Múltiples modelos animales muestran que si se
reanima con fluidos teniendo como meta,
presión arterial normal:
Mayor mortalidad
Mayor sangrado
Front Biosci (Landmark Ed) 2009 Jan 1;14:4631-9. Hemorrhagic shock: an overview
of animal models. Moochhala S1, Wu J, Lu J
17. Evidencia humanos
Houston, 598 pacientes
Randomizados a fluidos vs no fluidos antes de llegar a
pabellón
Trauma penetrante toracoabdominal
2 litros de SF de diferencia entre grupos
Sobrevida:
62% vs 70%
Bickel et al, NEJM, 331; 1105 - 1109, 1994
18. Evidencia humanos
R Dutton, 110 pacientes
Randomizados a PAM>100 vs PAM =80
Trauma penetrante y cerrado
toracoabdominal, fuera TEC
Edad <55
Sin diferencia en mortalidad
Dutton et al, Journal of trauma, 52; 1141, 2002
Pese a ser “negativo”,
cambió practica clínica
19. Por lo tanto…
Existe evidencia suficiente como para no
reanimar contra presión arterial en
pacientes que están sangrando
Mas que el número, parece ser mejor la
perfusión
Menos parece ser mejor
24. Resucitación Hemostática
OK, parece ser que fluidos no ayuda… pero que pasa
si estamos dando el fluido equivocado?
Concepto:
En un paciente con trauma, sangrando, no se
debe aportar ningún fluido que no ayude a la
coagulación o que transporte oxigeno
26. M ilita r y Con flict lea d s to
Tr a u m a M ed icin e Ad va n ces
EMCrit
27. Resucitación Hemostática
Se inicia y se ha desarrollado principalmente en
el mundo militar, pero:
Bancos de sangre andantes
Sangre completa, fresca
No se sabe si es extrapolable a población civil
Conflicto Afganistán
Menor muertos en la historia de USA, utilizando
este approach
28. Resucitación Hemostática
Dutton crea esta relación 1:1:1,
intentando reproducir sangre completa,
pero…
No es igual a pasar sangre fresca
Terminamos dando sangre apenas compatible
con la vida
No sabemos si datos militares se pueden
extrapolar
Parece mantenerse el beneficio, aun sacando todos los
estudios militares
29. 500 cc sangre
Hcto 38 – 50%, pqtas 150 – 400k, act coag 100%
1 U GR
Hcto 55%, 335 ml
1 U Plasma
act coag 80%, 275 ml
1 U plaquetas
5.5 x 1010 pqtas, 50 ml
150 ml anticoagulante, se centrifuga
1: 1: 1
Hcto: 29%, pqtas: 80k, act coag: 65%, 675 ml
z
z
30.
31. Resucitación Hemostática
Múltiples estudios que demuestran
beneficio, la mayoría malos
Solo 1 prospectivo
Beneficio se ha demostrado con
recambio de 1 volumen sanguíneo total
(8 – 10 U GR) en 24 horas
Quien entra a este manejo, como
predecir quien va a sangrar 1 volemia
en 24 horas???
32. Johansson P et al, Journal of Emergencies, Trauma and Shock, 15-21, Jun 2012
34. Page 1 of 2http:/ / www.ncbi.nlm.nih.gov/ pubmed/ 19204506?dopt= Abstract
BACKGROUND:
METHODS:
RESULTS:
CONCLUSIONS:
J Trauma. 2009 Feb;66(2):346-52.
Early prediction of massive transfusion in trauma: simple as ABC
(assessment of blood consumption)?
Nunez TC, Voskresensky IV, Dossett LA, Shinall R, Dutton WD, Cotton BA.
Department of Surgery, Division of Trauma and Surgical Critical Care, Vanderbilt University School of Medicine, Nashville,
Tennessee, USA.
Abstract
Massive transfusion (MT) occurs in about 3% of civilian and 8% of military trauma
patients. Although many centers have implemented MT protocols, most do not have a standardized
initiation policy. The purpose of this study was to validate previously described MT scoring systems
and compare these to a simplified nonlaboratory dependent scoring system (Assessment of Blood
Consumption [ABC] score).
Retrospective cohort of all level I adult trauma patients transported directly from the
scene (July 2005 to June 2006). Trauma-Associated Severe Hemorrhage (TASH) and McLaughlin
scores calculated according to published methods. ABC score was assigned based on four
nonweighted parameters: penetrating mechanism, positive focused assessment sonography for
trauma, arrival systolic blood pressure of 90 mm Hg or less, and arrival heart rate > or = 120 bpm.
Area under the receiver operating characteristic curve (AUROC) used to compare scoring systems.
Five hundred ninety-six patients were available for analysis; and the overall MT rate of
12.4%. Patients receiving MT had higher TASH (median, 6 vs. 13; p < 0.001), McLaughlin (median,
2.4 vs. 3.4; p < 0.001) and ABC (median, 1 vs. 2; p < 0.001) scores. TASH (AUROC = 0.842),
McLaughlin (AUROC = 0.846), and ABC (AUROC = 0.842) scores were all good predictors of MT,
and the difference between the scores was not statistically significant. ABC score of 2 or greater was
75% sensitive and 86% specific for predicting MT (correctly classified 85%).
The ABC score, which uses nonlaboratory, nonweighted parameters, is a simple
and accurate in identifying patients who will require MT as compared with those previously published
scores.
PMID: 19204506 [PubMed - indexed for MEDLINE]
MeSH Terms
LinkOut - more resources
9/ 12/ 12 3:12 PMEarly predictors of massive transfusion in co... [JAm Coll Surg. 2007] - PubMed - NCBI
BACKGROUND:
STUDY DESIGN:
RESULTS:
CONCLUSION:
J Am Coll Surg. 2007 Oct;205(4):541-5. Epub 2007 Aug 8.
Early predictors of massive transfusion in combat casualties.
Schreiber MA, Perkins J, Kiraly L, Underwood S, Wade C, Holcomb JB.
Department of Surgery, Oregon Health and Science University, Portland, OR 97239, USA. schreibm@ohsu.edu
Abstract
An early predictive model for massive transfusion (MT) is critical for management of
combat casualties because of limited blood product availability, component preparation, and the time
necessary to mobilize fresh whole blood donors. The purpose of this study was to determine which
variables, available early after injury, are associated with MT. We hypothesized that International
Normalized Ratio and penetrating mechanism would be predictive.
We performed a retrospective cohort analysis in two combat support hospitals in
Iraq. Patients who required MT were compared with patients who did not. Eight potentially predictive
variables were subjected to univariate analysis. Variables associated with need for MT were then
subjected to stepwise logistic regression.
Two hundred forty-seven patients required MT and 311 did not. Mean Injury Severity
Score was 22 in the MT group and 5 in the non-MT group (p < 0.001). Patients in the MT group
received 17.9 U stored RBCs and 2.0 U fresh whole blood, versus 1.1 U RBCs and 0.2 U whole blood
in the non-MT group (p < 0.001). Mortality was 39% in the MT group and 1% in the non-MT group (p
< 0.001). Variables that independently predicted the need for MT were: hemoglobin <or= 11 g/dL,
International Normalized Ratio > 1.5, and a penetrating mechanism. The area under the receiver
operator characteristic curve was 0.804 and Hosmer-Lemeshow goodness-of-fit test was 0.98.
MT after combat injury is associated with high mortality. Simple variables available
Display Settings: Abstract
PubMed
9/ 12/ 12 3:11 PMEarly risk stratification of patients with maj... [Resuscitation. 2011] - PubMed - NCBI
BACKGROUND:
OBJECTIVE:
DESIGNS:
PATIENTS:
MAIN OUTCOME MEASURES:
RESULTS:
Resuscitation. 2011 Jun;82(6):724-9. Epub 2011 Apr 1.
Early risk stratification of patients with major trauma requiring
massive blood transfusion.
Rainer TH, Ho AM, Yeung JH, Cheung NK, Wong RS, Tang N, Ng SK, Wong GK, Lai PB, Graham CA.
Department of Accident and Emergency Medicine, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin,
NT, Hong Kong. thrainer@cuhk.edu.hk
Abstract
There is limited evidence to guide the recognition of patients with massive,
uncontrolled hemorrhage who require initiation of a massive transfusion (MT) protocol.
To risk stratify patients with major trauma and to predict need for MT.
Retrospective analysis of an administrative trauma database of major trauma patients. A
REGIONAL TRAUMA CENTRE: A regional trauma centres in Hong Kong.
Patients with Injury Severity Score ≥ 9 and age ≥ 12 years were included. Burn patients,
patients with known severe anemia and renal failure, or died within 24h were excluded.
Delivery of ≥ 10 units of packed red blood cells (RBC) within 24h.
Between 01/01/2001 and 30/06/2009, 1891 patients met the inclusion criteria. 92 patients
required ≥ 10 units RBC within 24h. Seven variables which were easy to be measured in the ED and
significantly predicted the need for MT are heart rate ≥ 120/min; systolic blood pressure ≤ 90 mm Hg;
Glasgow coma scale ≤ 8; displaced pelvic fracture; CT scan or FAST positive for fluid; base deficit >5
mmol/L; hemoglobin ≤ 7 g/dL; and hemoglobin 7.1-10 g/dL. At a cut off of ≥ 6, the overall correct
Display Settings: Abstract
PubMed
9/ 12/ 12 3:13 PMProspective identification of patients at risk for m... [Am Surg. 2011] - PubMed - NCBI
Am Surg. 2011 Feb;77(2):155-61.
Prospective identification of patients at risk for massive transfusion:
an imprecise endeavor.
Vandromme MJ, Griffin RL, McGwin G Jr, Weinberg JA, Rue LW 3rd, Kerby JD.
Section of Trauma, Burns, and Surgical Critical Care, University of Alabama at Birmingham School of Medicine, Birmingham,
Alabama 35294, USA.
Abstract
Most retrospective studies evaluating fresh-frozen plasma:packed red blood cell ratios in trauma
patients requiring massive transfusion (MT) are limited by survival bias. As prospective resource-
intensive studies are being designed to better evaluate resuscitation strategies, it is imperative that
patients with a high likelihood of MT are identified early. The objective of this study was to develop a
predictive model for MT in civilian trauma patients. Patients admitted to the University of Alabama at
Birmingham Trauma Center from January 2005 to December 2007 were selected. Admission clinical
measurements, including blood lactate 5 mMol/L or greater, heart rate greater than 105 beats/min,
Display Settings: Abstract
PubMed
9/ 12/ 12 3:13 PMTrauma Associated Severe Hemorrhage (TASH)- Score: p... [JTrauma. 2006] - PubMed - NCBI
J Trauma. 2006 Jun;60(6):1228-36; discussion 1236-7.
Trauma Associated Severe Hemorrhage (TASH)-Score: probability of
mass transfusion as surrogate for life threatening hemorrhage after
multiple trauma.
Yücel N, Lefering R, Maegele M, Vorweg M, Tjardes T, Ruchholtz S, Neugebauer EA, Wappler F, Bouillon B, Rixen
D; Polytrauma Study Group of the German Trauma Society.
Department of Trauma and Orthopedic Surgery, University of Witten/Herdecke, Cologne Merheim Medical Center, Germany.
n.yuecel@t-online.de
Display Settings: Abstract
PubMed
Alta sensibilidad
con una
especificidad
inaceptablemente
baja
Brockamp et al, Critical Care, 2012, 16R:129
37. Resucitación Hemostática
Qué otros productos considera
la RH?
Calcio
Dilución y quelación por citrato
Cloruro idealmente
Controlar, al menos niveles normales
38. Resucitación Hemostática
Qué otros productos considera la RH?
Factor VII?
No utilizar en la urgencia
No hay ningún trabajo que demuestre beneficio
en mortalidad
No sirve si hay acidosis, hipotermia o resucitación
inadecuada
$1 por mcg
Dosis inicial 100 mcg/Kg, habitualmente 7000 mcg
39. Resucitación Hemostática
BACKGROUND:
METHODS:
J Trauma. 2010 Sep;69(3):489-500.
Results of the CONTROL trial: efficacy and safety of recombinant
activated Factor VII in the management of refractory traumatic
hemorrhage.
Hauser CJ, Boffard K, Dutton R, Bernard GR, Croce MA, Holcomb JB, Leppaniemi A, Parr M, Vincent JL, Tortella
BJ, Dimsits J, Bouillon B; CONTROL Study Group.
Department of Surgery, Harvard Medical School and Beth Israel Deaconess Medical Center, Boston, Massachusetts 02216,
USA. cjhauser@bidmc.harvard.edu
Abstract
Traumatic coagulopathy contributes to early death by exsanguination and late
death in multiple organ failure. Recombinant Factor VIIa (rFVIIa, NovoSeven) is a procoagulant that
might limit bleeding and improve trauma outcomes.
We performed a phase 3 randomized clinical trial evaluating efficacy and safety of
rFVIIa as an adjunct to direct hemostasis in major trauma. We studied 573 patients (481 blunt and 92
penetrating) who bled 4 to 8 red blood cell (RBC) units within 12 hours of injury and were still
bleeding despite strict damage control resuscitation and operative management. Patients were
assigned to rFVIIa (200 µg/kg initially; 100 µg/kg at 1 hour and 3 hours) or placebo. Intensive care
unit management was standardized using evidence-based trauma "bundles" with formal oversight of
compliance. Primary outcome was 30-day mortality. Predefined secondary outcomes included blood
Display Settings: Abstract
Performing your original search, the control trial, in PubMed will retrieve 250900 records.
PubMed
40. Resucitación Hemostática
Qué otros productos considera
la RH?
Concentrados protrombina
Europa: 4 factores, USA 3 factores
Actualmente elección para reversar TACO
Seguro, limpio, no muy caro
41. Resucitación Hemostática
Qué otros productos considera la RH?
Ácido tranexámico
1 gr en bolo, luego 1 gr en 8 horas
Controversias con el trabajo, sin embargo:
Muy barato, disponible, sin efectos adverso
Efecto en mortalidad
No esta claro como funciona
No baja uso de productos sangre
Cr a sh 2Cr a sh 2
42. Resumen
No usar fluidos que no coagulen o
transporten oxigeno
Usar en relación 1:1:1
Preocuparse del calcio, conocer
que otros coadyuvantes tenemos
43. Nuevo problema
OK, parece ser que encontramos un fluido
mejor que los cristaloides, ahora… cuanto,
como y para que pasamos???
Lo clásico era reanimar contra PA, sin
embargo se demostró que no es lo ideal
Aumenta la pérdida de sangre
Aumenta el uso de productos sanguíneos
Barre coágulos
44. Hipotensión permisiva
“Injection of a fluid that will increase blood
pressure has dangers in itself… if the pressure is
raised before the surgeon is ready to check any
bleeding that might take place, blood that is
sorely needed may be lost”
Cannon W, JAMA. 1919, 70; 618 - 621
Cirujano
45. All w ith M AP of 65
Normal Septic Trauma Trauma
EMCrit
47. 65 + P er fu sion +
P a in Con tr ol &
Sed a tion
EMCrit
48. Tendencia Actual
Más que el número de presión, importa la
perfusión
Dutton
Intercala bolos de fluido (GR + PFC) con fentanyl,
para mantener presiones mínimamente adecuadas
Llenando el estanque, pero manteniendo
hipotensión
Solo experiencia, nada de evidencia
50. Caso Clínico
Requiere de angiografía, que estará
disponible dentro de 4 horas…
Fijador de pelvis
GR + PFC + Pqtas, NO cristaloides ni coloides
Calcio
PAM alrededor 65 mmHg, balanceando
perfusión y riesgo de mayor sangrado
51. Conclusiones
Lo primero en trauma es identificar al
paciente en shock y ver de donde
sangra
Control anatómico del sangrado, si no,
nada vale la pena
52. Conclusiones
No dar nada que no ayude a coagular
o transporte O2
Den calcio!!!
No reanimar contra presión, reanimar
contra perfusión
53. Conclusiones
Si hospital pequeño o nivel 1rio o
2ndario: identificar lesiones críticas,
esfuerzos en traslado precoz
Si hospital de cuidado definitivo:
protocolo de transfusión masiva,
hipotensión permisiva, cirugía
control de daño, UCI
