Ben Edwards 14 th March 2014

1. Ben Edwards 14th March 2014 Damage Control Resuscitation

2. Damage control resuscitation Term used to describe key concepts • Permissive hypotension • Haemostatic resuscitation • Damage control surgery (DCS) Jansen J et al. Damage control resuscitation for patients with major trauma. BMJ 2009;338:b1778

3. Permissive hypotension • “A strategy of deferring or restricting fluid administration until haemorrhage is controlled, while accepting a limited period of suboptimum end organ perfusion” • Aim for Systolic BP 70-80 • Recommend use for up to 60 minutes • Aim to get control of bleeding within this time

4. Permissive hypotension 2 • Should not be used in those with isolated/concurrent head injuries • Aim Systolic BP>90 • “Normotension” • Therefore most applicable to penetrating trauma • BUT 40% polytrauma patients have traumatic brain injury! • Other terminology • Hypotensive resuscitation • Delayed resuscitation

5. Bickel WH et. al • Randomised 2 groups with penetrating trauma and BP <90 • Immediate • Delayed • BP raised to >100 post anaesthesia Bickell WH et al, NEJM 1994; 331:1105-9

6. Outcomes Bickell WH et al, NEJM 1994; 331:1105-9 • Statistically significant findings: • Survival higher in delayed group • Stay shorter in delayed group • Trend towards • Higher intra-op blood loss in the immediate group • ? More complications in immediate group • Not statistically significant

7. Outcome of Patients with Penetrating Torso Injuries, According to Treatment Group

8. Haemostatic Resuscitation • Early use of blood and blood products as primary resuscitation fluids Trauma induced coagulopathy causes •  mortality •  incidence of multi organ failure • Renal • Acute lung injury •  ICU length of stay

9. Trauma induced coagulopathy

10. Treatment of traumatic coagulopathy • Damage control resuscitation: • Correct coagulopathy • Limit duration of shock • Reduce haemodilution • Use high ratio blood component therapy • Limit use of crystalloids • Reduce hypothermia • Tranexamic acid • Factor VIIa • role remains unproven

11. Massive Transfusion protocol • Each hospital should have one • STH massive transfusion pack • 4 units packed red cells • 3 bags FFP • 2 bags cryoprecipitate • 1 adult dose platelets • Give empirically • Use clinical judgement, don’t wait for the clotting result

12. Evidence? Holcomb J et al. Annals of Surgery 2008;248:477-458 Increased Plasma and Platelet to Red Blood Cell Ratios Improves Outcome in 466 Massively Transfused Civilian Trauma Patients

13. More evidence Shaz BH et al. Transfusion 2010;50:493-500 • Increased number of coagulation products in relationship to red blood cell products transfused improves mortality in trauma patients

14. Tranexamic acid

15. Crash-2 trial • Over 20,000 patients ‘with or at risk of significant bleeding’ • 1g of Tranexamic acid over 10 minutes followed by a further 1 g over 8 hours reduced all cause mortality and deaths due to bleeding • Further analysis showed that must be given within 3 hours of injury • Independent standard for achieving best practice tariff (BPT) payment

16. Damage Control Surgery • “Temporary sacrifice of anatomy to preserve vital physiology” • Do only what is needed to stabilise and address life threatening injuries • Major surgery worsens the immune hit from trauma

17. Damage Control Surgery • DCS only if • Temp <35°C • INR >1.5 • Platelets <120 • BE> -5 • pH <7.25 • Critical care for further resuscitation • Serum lactate useful to assess adequacy of resuscitation

18. Summary • Damage control resuscitation practices are in evolution • As studies and evidence develop guidance will change • Military principles applied to a civilian population • Hybrid approach probably the future • Permissive hypotension, haemostatic resuscitation, DCS • Attention to detail vital