Unmanageable Bleeding in Trauma

1. Unmanageable Bleeding in Trauma Dr. VimalKoshy Thomas MD (EM), DNB (EM) Asst. Prof Emergency Medicine JMMCH , Thrissur

2. Objectives • ARE SHOCK PACKS BLIND AND WASTEFUL? • WOULD STANDARDIZED BLOOD LOSS ASSESMENT LEAD TO AN IDEAL TRANSFUSION?

3. No conflicts of interest

4. Unmanageable bleeding is leading cause of preventable death after Injury. • Coagulopathy will accompany such patients in more than 1/3 of cases.

5. Data at our centre

6. Patients requiring MTP in Trauma 2016-2018 33

7. Evolution of “Trauma induced coagulopathy”

8. Case Scenario A 26-yr-old man, without significant medical history and weighting around 80 kg, was brought to the ED after being run over by car. • HR- 140/mt • BP-70 systolic • RR - 35/mt

9. Pls place a large bore IV….

10. Pathophysiology of TIC Hypoperfusion Activated Protein C Catecholamines Fibrinolysis and Factor degradation Endothelial Changes Platelet Dysfunction Microparticles Traumatic coagulopathy

11. Mediators of TIC

12. Critical Role aPC in TIC Injury Hypoperfusion Protein C Thrombomodulin Thrombin T/TM complex Activated protein C

13. Increased Consumed PAi-1 High tPA aV aVIII PLASMIN PLASMINOGEN FORMATION DEGRADATION CLOT

14. Is our Patient at risk for massive transfusion ?

15. Pre-emptive VS Goal directed strategies • Preemptive • 1:1:1 transfusion • (PRBC: FFP: Platelet) • Using Clinical methods and resuscitative adjuncts Patient at risk for massive transfusion Goal directed PT/PTT/ Fibrinogen/ Viscoelastic assays Preemptive 1:1:1 transfusion (PRBC: FFP: Platelet) Using Clinical methods and resuscitative adjuncts

16. Clinical Methods • ATLS- Advanced Trauma Life Support

17. Airway: Patent Talking , Patent. • Breathing: Sp02-90%, RR-35/mt B/L air entry present . Improved with high flow oxygen. • Circulation: FAST positive, BP-70 after 500 ml Crystalloids. HR-130/mt. Pelvic trauma , B/L femur fracture. Femoral vessel injury. • Disability: GCS-14/15 (Confused and Anxious) • Exposure: Warmer placed , hypothermia prevented.

18. “Blood on the Floor , Look for five More”

20. HR- 140/mt BP-70 systolic Low Pulse Pressure RR - 35/mt Low urine output 14/15 <-10mEq/l Yes!!

21. Trauma patient….. • Activated MTP • Blood sent for laboratory investigations Routines, Cross Matching, PT/PTT

22. Pros and cons of clinical assessment • Pros: Helps guide resuscitation . • Cons: Underestimation of blood loss*

23. Resuscitation Adjuncts • Point of care Ultrasonography

24. Point of care Adjuncts Massive blood loss may produce only a slight decrease in initial hematocrit or hemoglobin concentration.* *ATLS 10th Edition

25. Preemptive Strategy ….there was no difference in the primary endpoints of 24hr and 30 day mortality

26. A small trial conducted in Canada comparing 1:1:1 to laboratory-guided blood component therapy showed that achieving 1:1:1 despite concerted efforts was only achieved in 57% of the patients; moreover, it resulted in increased plasma wastage

27. Our trauma patient… • We started the patient on Preemptive strategy of blood transfusion 8 units PRBC, 8 platelet and 8 plasma units. Following transfusion, Vitals- BP-90/60 , Hr- 98/mt However, 3 FFP were wasted.

28. ARE SHOCK PACKS BLIND AND WASTEFUL? • “….there is currently a lack of evidence to support empiric ratio-based blood product administration, including immediate platelet transfusion, for the seriously injured patient at risk for life-threatening hemorrhage”

29. Presumptive VS Goal directed strategies • Goal directed • PT/PTT/ Fibrinogen/ D-dimer/ • Viscoelastic Hemostatic assays Patient at risk for massive transfusion Presumptive 1:1:1 transfusion Using Clinical methods and resuscitative adjuncts Goal directed PT/PTT/ Fibrinogen/ Viscoelastic assays

30. Goal directed treatment of TIC • Standard Coagulation Assays- PT/PTT/ Fibrinogen/ D-dimer • Viscoelastic Hemostatic assays- TEG and ROTEM

31. Standard Coagulation Assays • TIC was initially defined by prolongation of the standard coagulation assays PTT and PT/International Normalized Ratio (INR). • PT represents factor VII • PTT represents factors XI, IX and VIII. • Both tests reflect the common pathway (factors X, V, and II).

33. Commonly used Cutoffs

34. Coagulation Assays Pros: Help Diagnosis of TIC. Cons: • Turn around time >= 60 minutes. • Coagulopathy are reported even normal ranges. • Does not give a ‘Snapshot’ of the patients current coagulopathy • Weak Guides to therapy.

35. Other tests • Fibrinogen deficit - Can predict TIC • D-dimer .

36. Visco-elastic Hemostatic Assays (VHA) • TEG and ROTEM • Assesses Multiple real time viscoelastic properties of coagulation. • thrombin generation, • platelet activity • fibrinogen cross-linking • providing a measurement of maximum clot strength • subsequent clot dissolution.

37. Against TEG A recent Cochrane review suggested that there was insufficient evidence to recommend TEG-based transfusion guidelines as superior to established transfusion practice.

38. For TEG 50% increase in Survival in the thrombelastography (TEG) guided group was significantly higher than the conventional coagulation assays (CCA) group

39. Viscoelastic VS Preemptive MTP

40. WOULD STANDARDIZED BLOOD LOSS ASSESMENT LEAD TO AN IDEAL TRANSFUSION? • VHA > Standard coagulation tests • Resuscitation to be tailored to the individual patient in real time. • Coordinates the different modalities available for treatment. • Provides Dynamic management as the patient’s condition changes

41. Conclusion • Standard coagulation tests and functional viscoelastic assays are commonly used in the diagnosis and management of TIC. • Balanced resuscitation is the mainstay of TIC treatment, but precise ratios for empiric resuscitation and optimal monitoring protocols for transfusion practice are needed.

42. Thank You!!