Remote Damage Control Resuscitation: An Overview for Medical Directors and Supervisors THOR Collaboration
Agenda • What is Remote Damage Control Resuscitation? • Putting RDCR into Practice – Control Hemorrhage – Resuscitate Hemorrhage – Adjunctive Measures • Timing of DCR matters: sooner is better, with decreased mortality benefits
What is RDCR?
Remote Prehospital (or far-forward/ austere) phase of resuscitation
+ Damage Control Damage Control: First, only do the things essential to keeping the ship afloat. Rotondo MF, Schwab CW, et al. J Trauma. 1993;35(3):375-82.
+ Resuscitation Emergency treatment to restore: Circulating volume Aid oxygen delivery Replace hemostatic potential (and a few other things…)
= RDCR (today in U.S. military) The essentials: • Hemorrhage control • Resuscitation • TXA • WHOLE BLOOD • Avoid clear fluids • Plasma (FDP) as a bridge to WB ROLO!
DCR Definitions The initial definition of DCR, by Holcomb and colleagues, states “DCR • addresses the entire lethal triad immediately upon admission to a combat hospital”. DCR principles include: compressible hemorrhage control; hypotensive • resuscitation; rapid surgical control of bleeding; avoidance of the overuse of crystalloids and colloids, prevention or correction of acidosis, hypothermia, and hypocalcemia; and hemostatic resuscitation (early use of a balanced amount of red blood cells (RBCs), plasma, and platelets). RDCR: REMOTE Damage Control Resuscitation has been defined as the • pre-hospital application of Damage Control Resuscitation (DCR) concepts. – The term RDCR was first published by Gerhardt and colleagues from the United States Army Institute of Surgical Research and since been promoted by the THOR Network. THOR Position Paper on Remote Damage Control Resuscitation: Definitions, Current Practice and Knowledge Gaps. Jenkins DH, et al.; SHOCK, Vol. 1, Supplement 3, 2014.
Why RDCR? HEMORRHAGIC SHOCK: Low cardiac output à Poor tissue perfusion à Oxygen debt à Acidosis à BLOOD FAILURE Fibrinolysis/ Coagulopathy/ Platelet dysfunction à More bleeding à DEATH… IN MINUTES Need to restore functionality of WB!
Goal of RDCR: Prevent the “Lethal Triad” (i.e. Blood Failure) Close to Point of Injury
DCR, and the case for RDCR • “Pre-surgical” resuscitation • Prepping the patient physiologically for best results during surgery • Preventing complications and shock • REMOTE DCR = moving the capability of DCR forward closer to the point of injury (POI) – It has been applied in the prehospital phase safely – It has been shown to decrease mortality if started as soon as possible
Putting RDCR into Practice
Control Hemorrhage • Core concept inherent in Tactical Combat Casualty Care (TCCC) protocols – Validated, universally accepted combat trauma management principles • Liberal use of tourniquets, hemostatic dressings, junctional tourniquets • Early and far-forward at the Point of Injury (POI) – Self- and Buddy-aid • Recognition of need for rapid evacuation to surgical care
TCCC Fluid Resuscitation from Hemorrhagic Shock: 2014 Updated Fluid Resuscitation Plan Order of precedence for fluid resuscitation of casualties in hemorrhagic shock 1. Whole blood 2. 1:1:1 plasma:RBCs:platelets 3. 1:1 plasma: RBCs 4. (tie) Plasma (liquid, thawed, dried) or RBCs alone ….. 8. Hextend 9. (tie) Lactated Ringers or Plasma-Lyte A Butler et al – JSOM 2014
Why WB? It’s simple! Don’t make things worse (clear fluids)! Give the patient what he or she is losing! Keep it simple (one product)!
Benefits of Low Titer Group O Whole Blood Compared to Blood Components for Blood Failure Efficacy • – The cold stored platelets provide improved hemostasis compared to room temperature platelets – More concentrated product that contains less anticoagulants and additive solution than an equal amount of components Safety • – Reduced risk of hemolysis from the low titer minor incompatible plasma compared to the risk from untitered minor incompatible plasma or platelets – Reduced risk of bacterial contamination compared to room temperature stored platelets – Impressive safety record with over 1 million units transfused in combat and civilian settings Logistics • – Increased access to platelets for both pre-hospital and early in-hospital resuscitations – Simplifies and accelerates the provision of all blood components needed to treat hemorrhagic shock
WB vs. Components: More Concentrated, Simpler WB 4°C Components (1:1:1) Hgb 12-13 9 HCT 35-37 28 PLT 138-165 90-120 Fibrinogen, Normal @ All 62% dilution @ Factors baseline, FVIII ≥ baseline, plus loss 50% d7 FVIII TEG Nearly normal Reduced vs. WB d21 PLT aggregation ≥ 50% baseline Nearly complete loss d7-10 d5 in RT-PLT Practical aspects 8 bags, one 13 bags, three storage (4L) storage mode modes (8 U, 4000 ml) (6:6:1, 4150 ml)
Anti-coagulants and Additives 1:1:1 Component Therapy: Whole Blood x 6 Units: 6 x 63ml = 378ml 6 x RBC (AS-5) 6 x 120 ml = 720ml 6 x FFP 6 x 50 ml = 300ml 1 x aPLT 1 x 35 ml = 35ml Total =1055ml Total: 378ml 3 times the volume of anticoagulant & additives in reconstituted whole blood from components (1:1:1) compared to whole blood! Spinella PC, J Trauma. 2009;66:S69-76
Whole Blood Recent Combat Data
Adjunctive DCR Measures • TXA administration • Calcium administration • Trending vital signs/monitoring – Consider monitoring urine output – Consider measuring point of care labs (lactate) • Nursing care • Warming/maintaining body temperature of the patient • Wound care/antibiotics • Pain control
Tranexamic Acid Summary • CRASH-2: 20,211 patients, 274 hospitals, 40 countries • Tranexamic acid is the only drug to have a demonstrated mortality benefit in trauma. • Timing of administration appears to be critical in trauma (use only within 3 hours of injury). Overall safety profile is very reassuring. • Only available dosing guidance provided by CRASH-2 (1gm load over 10 minutes, then 1gm over 8 hours). • Tranexamic acid is no longer patent-protected. DoD formulary cost is $39.12 for a 1gm vial (about $80 total for the CRASH-2 regimen).
Calcium Supplementation CALCIUM: hypoCa à long QTc, decreased cardiac output, coagulopathy, seizures, etc. 97.4% of trauma MTP patients hypocalemic (<1.12mmol/L) 50-70% severe (<0.8-0.9mmol/L) à More coagulopathy à More blood transfused à Double mortality (49% vs. 24%) à Calcium replacement after 4U, but never resolved (still <1.12mmol/L) One unit of citrated blood product can drop iCa Give 2g CaCl or 6gm Ca gluconate EARLY (<4 U transfused) Giancarelli. J Surg Res. 2016. Ho. Anesth Intens Care. 2011.
Timing of RDCR
Time to Death: KIA/DOW Golden Hour is too late to start DCR… Number of KIA and DOW Deaths by Time Increment (AFG) N=457 KIA DOW 120 Must start resuscitation pre-hospital: 100 Remote DCR (RDCR)! 80 60 40 20 0 5 minutes >5 >30 >60 >90 >2 hours >4 hours >6 hours >8 hours >10 hours >12 hours >24 hours >1 week or less minutes minutes minutes minutes to 4 hours to 6 hours to 8 hours to 10 to 12 to 24 to 1 week or more to 30 to 60 to 90 to 2 hours hours hours hours minutes minutes minutes Shackelford, et al. JTS 2016.
RDCR: immediately if not sooner! *34 min from injury Increasing duration of shock is not helpful. Think BLS. How many minutes before myocardium and brain die? Shackelford/JTS 2016.
Golden Hour is too late… NEED BLOOD at POI Number of KIA and DOW Deaths by Time Increment N=457 KIA DOW 120 100 80 60 40 20 0 5 minutes >5 >30 >60 >90 >2 hours >4 hours >6 hours >8 hours >10 hours >12 hours >24 hours >1 week or less minutes minutes minutes minutes to 4 hours to 6 hours to 8 hours to 10 to 12 to 24 to 1 week or more to 30 to 60 to 90 to 2 hours hours hours hours minutes minutes minutes JTS 2016.
RDCR Summary • Hemorrhage and injury cause acute blood failure or hemovascular dysfunction (leading to the “lethal triad”) . • DCR treats drivers of blood failure simultaneously with blood/blood products (and TXA). • DCR is most effective if started immediately: RDCR . • Risk/benefit of products should be considered in light of exsanguination mortality. • Simplicity is a virtue: LTOWB . • Push the capability forward to save lives close to POI.
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