Blunt Abdominal Trauma (PowerPoint) by hedongchenchen


									       Missouri EMS
       Central Region

    November 2011 Webinar
Contemporary Fluid Resuscitation

      Jeffrey Coughenour, MD, FACS
           Assistant Professor of Surgery
   Medical Director, Missouri EMS Central Region
• Monthly educational opportunity for
  providers within the Central Region
• Focus
  – Performance improvement, actual case review
  – Literature review
  – Discuss practice management guidelines
• Introduce contemporary trauma resuscitation
  and review the supporting evidence
  –   Damage-control or hemostatic resuscitation
  –   Massive transfusion
  –   Hypertonic saline
  –   Other adjuncts for coagulopathy
•   Walter B. Cannon
•   Fight or Flight
•   Traumatic Shock, 1923
•   CNS-mediated “toxic factor”
    released from tissue

“…if the pressure is raised before the surgeon
 is ready to check the bleeding that may take
 place, blood that is sorely needed may be lost”
• Combination of classic shock states
  – Loss of circulating blood (hemorrhagic)
  – Myocardial depression (cardiogenic)
  – Hypoperfusion or reperfusion injury (neurogenic)

  End result—decreased oxygen delivery and
             cellular dysfunction
• Compensated shock
  – Increase in HR, vasoconstriction of non-essential
    ischemic-tolerant vascular beds
• Decompensated shock
  – Lack of adequate oxygen delivery builds up
    “oxygen debt”, leads to cellular dysfunction and
    damage, reperfusion injury, reversible
• LR or NS then PRBC’s
  – LR
     • Diarrhea fluid from 1880, acidotic, no clotting factors, 200 mL
       intravascular at 60 min, proinflammatory
  – PRBCs
     • Each unit increases MOF, old blood = high K+, acidotic, no clotting factors,
• Standard resuscitation approach was to
  escalate use of fluids that may worsen
  abnormal physiology
  – 2L LR (3:1), then PRBC (10 units), then FFP (2 units)
    Pre-Hospital IV Fluid Administration is
Associated with Decreased Survival in Severely
           Injured Trauma Patients
• Abstract, EAST 2009, Haut ER et al
• NTDB analysis, mortality as primary outcome analysis
• Subgroup analysis: Mechanism, ISS, hypotension, coma, need
  for immediate surgery
• 776,734 patient data sets evaluated
   –   Unadjusted mortality higher 4.8 vs. 4.5% (p<0.001)
   –   Odds Ratio of death for IV fluid group—1.3
   –   Subset analysis consistent in all groups
   –   Association greatest in penetrating mechanism, hypotension, need
       for immediate surgery
Damage Control or Hemostatic
     Prospective evaluation of preoperative fluid
resuscitation in hypotensive patients with penetrating
          truncal injury: a preliminary report
                  Martin, Bickell, Pepe, Burch, Mattox
           J Trauma 1992 Sep;33(3):354-61; discussion 361-2

• Randomization of immediate vs. delayed fluid resuscitation is
  penetrating truncal injury with hypotension (< 90 mmHg)
• Immediate n=96, 56% survival to discharge
• Delayed n=81, 69% survival to discharge
• Survival advantage not statistically significant
• All other endpoints, little difference
   Immediate versus delayed fluid resuscitation for
 hypotensive patients with penetrating torso injuries
               Bickell, Wall, Pepe, Martin, Allen, Mattox
               N Engl J Med 1994 Oct 27;331(17):1105-9

• 598 adults randomized to immediate or delayed resuscitation
• Immediate group
   – 62% survival, 30% one or more complications
• Delayed group
   – 70% survival, 23% complications
• Survival p-value=0.04
• Complications: ARDS, sepsis, ARF, coagulopathy, wound
  infection, pneumonia
        Fundamental Change
• Delay in hemorrhage control—early
  preventable deaths
• Large-volume crystalloid followed by
  transfusion worsens reperfusion injury and
  systemic inflammation—late preventable
• New methods of resuscitation and monitoring
  required to prevent late trauma deaths
           Select Population
• About 10% of injured will be hypotensive
• Of those, 3-5% due to blood loss
• Early identification of
  – Abnormal physiology
  – Injury parameters
• Pre-determined resuscitation strategy
             Pattern Recognition
• Exam findings
  – Decreased mental status from injury or shock
  – Suspected TBI
  – Clinical coagulopathy
• Laboratory values
  –   INR > 1.5
  –   Base deficit > 6
  –   Hemoglobin < 11
  –   Hypothermia (<96) or hypotension (SBP <90)
            Pattern Recognition
• Trunk, axillary, groin, or neck wounds not
  controlled by local wound care
  – Direct pressure
  – Tourniquet
  – Hemostatic dressings
• Proximal amputation or mangled extremity
• Hemoperitoneum with shock
• Massive hemothorax
  – >2000 mL initially or >200 mL per hour for 4 hours
        Hemostatic Resuscitation
•   Crystalloid to maintain radial pulse, alertness
•   PRBC:FFP 3:2
•   PRBC:Platelets 5:1
•   Adjuncts for coagulopathy
•   With cessation of hemorrhage and
    normalization of physiology, minimal
Hypertonic Saline
            Hypertonic Saline
• Hypothesized benefits
  – Intravascular volume expansion
  – Immunomodulatory
  – Improved microcirculatory flow
  – Inotrope via myocardial sodium channels
• Optimal formula ?
  – 3%, 7.5%, 7.5% with dextran
Hypertonic Resuscitation of Hypovolemic Shock after
           Blunt Trauma: A Randomized
                  Controlled Trial
                Bulger EM, Jurkovich GJ, Nathens AB
                 Arch Surg 2008 Feb;43(2):139-48

• 250 mL of 7.5% hypertonic saline and 6% dextran (HSD) vs. LR
• 209 patients enrolled, stopped (futility) after second data
• No significant difference in ARDS-free survival
• Benefit in subset requiring >10 unit transfusion in first 24
   Prehospital resuscitation with hypertonic saline-
  dextran modulates inflammatory, coagulation and
   endothelial activation marker profiles in severe
          traumatic brain injured patients
                Rhind SD, Baker AJ, Morrison LJ, et al
                  J Neuroinflamm 2010 Jan 18;7:5

• Impact of prehospital resuscitation on selected cellular and
  soluble inflammatory/coagulation markers
• Flow cytometry was used to analyze leukocyte cell-surface
  adhesion (CD62L, CD11b) and degranulation (CD63, CD66b)
• HSD attenuated the upregulation of leukocyte/endothelial cell
  proinflammatory/prothrombotic mediators
Blood and Blood Component
           Massive Transfusion
• MOF lower, 9 vs 20%, p < 0.01
• 30 day survival higher 57 vs 38%, p < 0.01
• Benefit = earlier product administration

                                               JTrauma 2009
More than 20 papers involving > 2,000 patients
In severely injured patients, early product administration
     resulted in less product use and increased survival
Fresh Frozen Plasma Is Independently Associated With
   a Higher Risk of Multiple Organ Failure and ARDS
      The Inflammation and the Host Response to Injury Investigators
                   J Trauma 2009 Aug 67(2):221-230

• Investigate effect of plasma rich components of resuscitation
  after blunt trauma
• N= 1,175 (65% FFP, 41% platelets, 28% cryo)
• With each unit of FFP, odds ratio 2.1 and 2.5 for MOF and
An FFP:PRBC Transfusion Ratio >/=1:1.5 is Associated
    With a Lower Risk of Mortality after Massive
     The Inflammation and the Host Response to Injury Investigators
                   J Trauma 2008 Nov;65(5):986-93

• In civilian blunt trauma patients requiring ≥ 8 units
  PRBCs in the first 12 hours…
   – 52% mortality reduction
   – No effect on MOF or nosocomial infections
   – Two-fold increase in ARDS
Lyophilized Plasma for Resuscitation in a Swine Model
                  of Severe Injury
Nicholas Spoerke, MD; Karen Zink, MD; S. David Cho, MD; Jerome Differding,
  MPH; Patrick Muller, BS; Ayhan Karahan, MD; Jill Sondeen, PhD; John B.
                   Holcomb, MD; Martin Schreiber, MD
                     Arch Surg 2009;144(9):829-834

• LP clotting factor activity decreased average 14%
• Survival, HR, blood loss, lactate, coagulation profiles similar
  between PRBC:FFP and PRBC:LP groups
• Decreased IL-6 production with LP

         However, not likely available for several years…
• Recombinant Factor VIIa
  – Creates thrombin burst, safe, pH > 7.2
• Prothrombin complex concentrates
  – Hemophilia, emergency reversal of Coumadin
• Tranexamic acid
  – Stops pathologic clot-breakdown (fibrinolysis)
    after massive hemorrhage
            Summary Points
• Surgical hemorrhage control is paramount!
• Limitation of the amount of crystalloid
  improves outcomes
• Early blood products in pre-determined
  amounts are effective
• rFVIIa, PCC, and tranexamic acid are likely
  useful adjuncts to hemostatic resuscitation
          Summary Points
Search hypotensive, hemostatic, or damage-
            control resuscitation
December 2011 Webinar

  The Surgical Airway
      Questions ?

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