Civilian Trauma Care COL(ret) George E Peoples, MD, FACS 6 April - - PowerPoint PPT Presentation

Battlefield Innovations Impacting Civilian Trauma Care

COL(ret) George E Peoples, MD, FACS 6 April 2018

Military Contributions to Trauma Care

• Napoleanic Wars

– Ambrose Parre – Wet-to-dry dressings

• Civil War

– Letterman - Field ambulances

• WWII

– Antibiotics

• Korea/Vietnam

– Surgical techniques – Vascular and Colon injuries – Use of the helicopters for medevac

U.S. CASUALTIES

GWOT vs. WWII and Vietnam

Advances in Combat Casualty Care

• CFR rate dropped to <10%
• Contributors

– Body armor – Air superiority – FSTs

• Proximity
• Damage Control Surgery
• Hemostatic resuscitation

The 274th Surgical Team

Advances in Combat Casualty Care

• CFR rate dropped to <10%
• Contributors

– Body armor – Air superiority – FSTs

• Proximity
• Damage Control Surgery
• Hemostatic resuscitation

Damage Control Surgery

• Principle = don’t do too much
• Abbreviated laparotomy for severely injured

patients

– Stop bleeding – Fix life threatening complications – Control contamination

• Do just enough to stabilize for transport to

the next level of care

Advances in Combat Casualty Care

• CFR rate dropped to <10%
• Contributors

– Body armor – Air superiority – FSTs

• Proximity
• Damage Control Surgery
• Hemostatic resuscitation

• Major leading cause of potentially preventable death

was truncal hemorrhage

J Trauma, Feb 2008

Hemorrhage 79% Airway 12% CNS 4% MSOF 6% Data includes 107 causes of death in 85 potentially survivable casualties

Causes of Potentially Survivable Deaths OCT 01 to NOV 04

Ax / Neck / Groin Hem 21% Ext Hem 31% Torso Hem 48%

Breakout of Potentially Survivable Hemorrhagic Deaths N =85

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Prehospital First 24 hours After 24 hours Percentage of deaths Hemorrhage CNS Other

Data adapted from: Acosta, et al. J Am Coll Surg 1998 & Sauaia, et al. J Trauma 1995

Bleeding to death is an acute problem Earlier control of hemorrhage should save lives

Civilian Hemorrhage Data

35

Acidosis Hypothermia

Coagulopathy

Death

Brohi K, et al. J Trauma, 2003. MacLeod J, et al. J Trauma 2003

• Rapid progress in trauma care occurs during a war.
• Damage control resuscitation addresses diagnosis

and treatment of the entire lethal triad immediately upon admission.

• High FFP & platelet to PRBC ratio (balanced resusc.)

Holcomb, JB. J Trauma. 2007; 62(2): 307-310

Damage Control Resuscitation: Directly Addressing the Early Coagulopathy of Trauma

[Special Commentary]

Holcomb, John B. MD, FACS; Jenkins, Don MD, FACS; Rhee, Peter MD, FACS; Johannigman, Jay MD, FS, FACS; Mahoney, Peter FRCA, RAMC; Mehta, Sumeru MD; Cox, E Darrin MD, FACS; Gehrke, Michael J. MD; Beilman, Greg J. MD, FACS; Schreiber, Martin MD, FACS; Flaherty, Stephen F. MD, FACS; Grathwohl, Kurt W. MD; Spinella, Phillip C. MD; Perkins, Jeremy G. MD; Beekley, Alec C. MD, FACS; McMullin, Neil R. MD; Park, Myung S. MD, FACS; Gonzalez, Ernest A. MD, FACS; Wade, Charles E. PhD; Dubick, Michael A. PhD; Schwab, C William MD, FACS; Moore, Fred A. MD, FACS; Champion, Howard R. FRCS; Hoyt, David B. MD, FACS; Hess, John R. MD, MPH, FACP

The “Lethal Triad” Revisited

Acidosis, coagulopathy, & hypothermia are symptoms Treat the central causes

• f the lethal triad

Damage Control Resuscitation

• Mindset which involves

– Permissive hypotension – Minimizing aggressive crystalloid use – Early use blood products such as PRBC and empiric use of component therapy

• Continued prioritization of surgically

controlling bleeding sources

6 Core Principles of DCR

• Compressible hemorrhage control
• Hypotensive resuscitation (Permissive hypotension)
• Rapid surgical control of bleeding
• Avoidance of the overuse of crystalloids and colloids
• Prevention or correction of acidosis, hypothermia &

hypocalcemia

• Hemostatic resuscitation

• Weak or absent radial pulse
• Abnormal mental status
• Age ≥ 55

Damage Control Resuscitation

Pattern Recognition

• 3442 total patients
• 680 received 1+ units blood in first 24 hours
• 204 transferred from another facility
• 29 known under age 18
• 81 Security Internees
• 44 Incomplete data
• Total of 302 patients - study population

– 80 patients (26.5%) required MT – Received 63% of blood products transfused McLaughlin, et al, J Trauma 2008; 64:S57-63

Who Needs DCR?

• Acidosis

Base Deficit > 5

• Coagulopathy

INR > 1.5

• Hypotension

Systolic B/P < 90(110?)

• Anemia (blood loss)

HgB < 11

• Hypothermia

< 96. 5o

Presence of any 2 predicts need for DCR 3 or more should mandate DCR

MT Scoring System

SBP < 110 HR > 105 Hct < 32 pH < 7.25 AUROC = .839

10 20 30 40 50 60 70 80 90 1 2 3 4 Score % Probability of Massive Transfusion

ABC Score

• Four Parameters

assigned a score of 0-1

– Penetrating Mechanism – Positive FAST – Arrival SBP <90 – Arrival HR >120

• A score of 2 was

predictive for MT

Cotton BA, et al, J Trauma 2010; 69: S33-39

Electrolytes (mmol/L) avg. unit of FFP ~ 300cc

Na 165 (48mmol/unit) K 3.3 (1.0mmol/unit) Glucose 20 Calcium 1.8 Citrate 20 Lactate 3 pH 7.2-7.4 Phos 3.63

Which is a better resuscitative fluid?

• McClelland RN, Shires GT, Baxter CR, Coln CD, Carrico CJ. Balanced salt solution in the

treatment of hemorrhagic shock. JAMA. 1967.

• FD Moore, Shires G. Moderation. Annals of Surg. 1968.
• Rhee et al. Human neutrophil activation and increased adhesion by various resuscitation
• fluids. Crit Care Med. 2000.
• Brandstrup B, et al. Effects of IV fluid restriction on postop complications: a comparison
• f two perioperative fluid regimens. Annals of Surg, 2003.
• NHLBI ARDS NET Clinical Trials Network; Wiedemann HP, et al. Comparison of two fluid-

management strategies in acute lung injury. NEJM 2006. Shock, 2006

Paradigm Shift

Damage Control Resuscitation

Borgman et al., J Trauma 2007 31% 46%

6 Core Principles of DCR

• Compressible hemorrhage control
• Hypotensive resuscitation (Permissive hypotension)
• Rapid surgical control of bleeding
• Avoidance of the overuse of crystalloids and colloids
• Prevention or correction of acidosis, hypothermia &

hypocalcemia

• Hemostatic resuscitation

Civilian Experience 1:1:1 Transfusion protocol

Author Location year beneficial Optimal FFP:PRBC Kashuk Denver 2008 No 1:2 Gunter Nashville 2008 Yes 2:3 Duchesne NOLA 2008 Yes 1:1 Sperry Pittsburg 2008 Yes 1:1.5 Scalea Baltimore 2009 No TBD Snyder Birmingham 2009 No Survival bias

• 11,185 screened and 680 were randomized

– Blood product ratios of 1:1:1 (338) vs 1:1:2 (342)

• No significant difference in mortality, ARDS, MODS, VTE, sepsis, and

transfusion-related complications

• No difference in PRBC transfused
• 1:1:1 ratio

– higher rate of hemostasis at 24 hours – Shorter time to hemostasis

• 34,000 patients in 10 medical centers
• 94% hemorrhagic deaths occurred within 24hrs

– 58% within the first three hours (mean 2.6 hours)

• At 3hrs only 10% of survivors had not received

plasma

Holcomb, et al, JAMA Surg, 2013 February;148(2): 127-136

• Higher FFP and Plt to PRBC transfusion ratios EARLY

resulted in higher survival

• After 6 hours, survival advantage of high ratio

decreases

• No advantage after 24 hours

Holcomb, et al, JAMA Surg, 2013 February;148(2): 127-136

PROMMTT - Survivors

• For each hour survived,

more likely to have FFP:PRBC ratio > 1:2

• 30 min 29%
• 1h 47%
• 2hr 69%
• 3hr 78%
• 6hr 84%

PROMMTT- Survivors

• PLT: PRBC ratio > 1:2
• 30min 1%
• 1hr 14%
• 2hr 40%
• 3hr 60%
• 6hr 80%

Wrapped Up in Ratios

• It’s not about exact ratios
• It’s about principles

– replace blood with blood – minimize crystalloid – start it early

• Make it AUTOMATIC!

Joint Theater CPG

www.usaisr.amedd.army.mil/clinical_practice_guidelines.html

Austere Environment

• “walking blood bank”
• prescreened donors
• provides fresh, warm red

cells, clotting factors, and platelets

Don’t have FFP or platelets?

Component Therapy vs Whole Blood

Component Therapy:

1U PRBC + 1U PLT + 1U FFP + 1 U cryo 680 COLD mL

• Hct 29%
• Plt 80K
• Coag factors 65% of initial concentration
• 1000 mg Fibrinogen

WWB: 500 mL Warm Hct: 38-50% Plt: 150-400K Coag: 100% 1000 mg Fibrinogen

• Armand & Hess, Transfusion Med. Rev., 2003

• Proven utility of whole blood (WB) transfusion in combat
• Group O whole blood safe universal donor
• Use of PLT preserving leukopore filter
• WB stored at 4oC retains PLT function for 15 days

Spinella, et al, Transfusion, 2016;56;S190–S202

Summary

• Early identification of patients requiring massive

transfusion continues to be problematic

• Balanced/hemostatic resuscitation as early as

possible

– POI administration of FFP? – Permissive hypotension

• Avoid unnecessary crystalloid
• Don’t get hung up on the ratio

Conclusions

• Hemorrhage control

– Liberal use of tourniquets – REBOA

• Reinforced the principles of DCS
• Damage control resuscitation

– Hemostatic resuscitation

• Early use of blood and blood products

– 1:1:1 ratio – Whole blood – FFP with first responders