Internal Bleeding

Resuscitation in Emergency Departement (ED)

Tommy Sunartomo
Anestesiology & Reanimation Departement
Medical Faculty of Airlangga University
RSUD Dr. Soetomo Surabaya

Symposium and Workshop: Emergency for Every Doctor January 2018

• Trauma → Internal Bleeding
▪ Blunt
▪ Penetrating
• Internal Bleeding
• Collection or accumulation of blood in the :
• Thoracal Space
• Intra Peritoneal Space
• Retro Peritoneal Space
• Pelvic Cavity
ATLS Concept
▪ ABCDE approach to evaluation and treatment
▪ Treat greatest threat to life first
▪ Definitive diagnosis not immediately important
▪ Time is of the essence
▪ Do no further harm
Concept of Initial Assessment

Preparation
Detailed
Primary Reevaluation
Secondary
Survey
Survey
Resuscitation Definitive
Adjuncts Reevaluation
Care
Adjuncts
Reevaluation
Primary Survey
Airway with C-Spine protection
Breathing / ventilation / oxigenation
Circulation : stop the bleeding
Disability / neurological status
Expose/ Environment / body temperature
Basic Principal Management
• Stop the bleeding
• Restore the volume
• The goals haemorrhage
− minimize :
− restore organ perfusion and tissue oxygenation
− prevent hypothermia, coagulopathy and acidosis
− optimize patient outcome
 Interventions

Hemostatic Direct
resuscitation Pressure/
tourniquet

Angio STOP Reduce pelvic

embolization the volume
bleeding

Splint fractures Operation

Hemostatic Agents
Estimate Blood Loss
Clinical Presentation
• Depend on Estimate Blood Loss
• Class I : < 15% EBV} Hemodynamic Stable
• Class II : 15 – 30% EBV
}
• Class III : 30 – 40% EBV
Hemodynamic Unstable

• Class IV : > 40% EBV

RESPONSE to INITIAL FLUID THERAPY
(20ml/KgBW Crystaloid)
RAPID RESPONSE

TRANSIENT RESPONSE

NO RESPONSE
Haemodynamic Stable
• Closed observation & monitoring
• Maintenance fluid
• Further diagnostic examination
• Endovascular intervention ?
• Correction of coagulopathy
• Haemostatic agents ?
Haemodynamic Unstable
• < C > ABC resuscitation
• Permissive hypotension
• Limitation of crystalloid
• Early use of blood and blood products
• Early use of TXA
• Surgical exploration-Surgical Resuscitation
 Damage-Control Resuscitation

Permissive Rapid definitive Prevention / Treatment

hypotension/ control of bleeding
Hypotensive
resuscitation
Blood Fluid Surgery Interventional Hypothermia
pressure restricted radiology
targeted /controlled Acidosis
Transfusion
Coagulopathy
Hypocalcemia
 Permissive Hypotension
(Hypotensive Resuscitation)

• Targetting lower blood pressure until definitive

haemostatic is achieved
• SBP 80-90mmHg, MAP 50-60mmHg
• Limitation of crystalloid resuscitation
• Early use of blood and blood products
• Blunt trauma ?, TBI ?, SCI ?
• Raising intravascular pressure, reducing blood
viscosity and dislodgement haemostatic plug →
increase blood loss
 Trauma pembuluh darah

Vasospasme

Mengerutkan robekan
Menurunkan aliran darah

Agregasi trombosit

Sumbat lunak
20 mnt
Beb.
Cascade koagulasi
Hari s/d
Terbentuk fibrin
minggu
Sumbat lebih keras
24 jam
Fibrin yang lengkap Penyembuhan
Tahan terhadap tensi normal pembuluh darah
 Pemberian Cairan Agresif

 MAP Hemodilusi

Dilusi Dilusi Viskositas

F.pembekuan eritrosit

Vasospasme hilang
Cascade Oksigenasi
koagulasi jaringan 
terganggu
Trombus Vasospasme
rusak/hanyut

Perdarahan bertambah
 Restrictive Fluid Administration

▪ intravenous fluids should be minimized.

▪ Aggressive fluid resuscitation results:

▪ worsening coagulopathy,
▪ an exaggerated trauma-related systemic inflammatory
response syndrome (SIRS),
▪ an increased incidence of adult respiratory distress syndrome
(ARDS), pulmonary edema, compartment syndrome, anemia,
thrombocytopenia, pneumonia, electrolyte disturbances, and
overall worse survival
 Hemostatic Resuscitation

▪ One of the main pillars of DCR is early and

aggressive transfusion of blood products aiming
for ratio of PRBCs, FFP and Platelets that
approximates 1:1:1

▪ Massive transfusion is typically defined as a

transfusion of 10 or more units of PRBCs within
the first 24h of injury
 Role of Hemostatic Adjuncts

These agents may:

▪ Decrease :
▪ mortality,
▪ transfusion requirements,
▪ rates of transfusion-related organ failure among
certain trauma patients.

▪ BUT, increase thromboembolic events

 Hemostatic Adjuncts

▪ Tranexamic acid:
▪ Prevent fibrinolysis
▪ Useful within 3 hours of injury
▪ Recombinant human factor VIIa:
▪ Does not decrease mortality
▪  thrombo-embolic complications
▪ Prothrombin complex, which contains factors II, VII, IX,
X, C,and S:
▪  mortality,  transfusion requirements, 
complications, &  lengths of stay
 Hemostatic Adjuncts

▪ Anti-fibrinolytic agents
▪ Early administration of tranexamic acid (TXA), an anti-
fibrinolytic agent, (slightly decrease the risk of death from
bleeding)

▪ Factor-concentrates
▪ recombinant factor VIIa or prothrombin complex
concentrates (PCCs) (lack of evidence)
 Resuscitation Goals and Monitoring

● Coagulation test is inappropiate

● PRBCs should be given to target a hemoglobin >7 g/dL,

● FFPs to target an international normalized ratio (INR) <2,

● Platelets to target a count >50,000,

● Cryoprecipitate to target a fibrinogen level >100 mg/dL.

● The use of thrombo-elastography-based protocols

(promising results)
THEORY OF TRAUMATIC COAGULOPATHY
As primary event modified by promoters

Mc Leod, JBA, Arch Surg 143, Aug.2008

THEORY OF TRAUMATIC COAGULOPATHY
As secondary event

Mc Leod, JBA, Arch Surg 143, Aug.2008

 Problems in Hemorrhagic Shock
Coagulopathy

Acidosis

Severe trauma Bleeding Tissue

hypoxia

Hypothermia

Colloid and Dilution of

Crystalloid infusion Coagulation factors
And platelets

Massive RBC
transfusion

Moore EE : Am J Surg 172: 405-410 1996

 H.M. A. Kaafarani, G. C. Velmahos
Scandinavian Journal of Surgery 0: 1–8, 2014

Damage Control Resuscitation and Surgery Algorithm

Pre hospital Care
Scoop and Run Injury

Minimize Fluid Resuscitation

Prevent Hypothermia

GOAL:
Pre Hospital Care
Get the patient to the trauma Less than 20 minutes
center
 Resuscitation

Allow permissive hypotension

Administer blood and blood
products early
Minimize fluid resuscitation
Start Tranexamic Acid
Start massive transfusion
protocol
Emergency Room
Less than 30 minutes
GOAL:

Mobilize promptly to OR/IR

Suite
 Operating Theater

Allow permissive hypotension

Aim for 1:1:1
PRBC/FFP/Platelets ratio
Administer cryoprecipitate
Abdominal packing
Temporary abdominal closure

Abbreviated surgical
GOAL: Procedure

Control surgical bleeding Less than 90 minutes

Control contamination
 Intensive Care (1)

Reverse hypothermia

Reverse coagulopathy

Reverse acidosis

Hemodynamics support

GOAL: Intensive Care Unit

12 – 36 hours
Resuscitate
Reverse Triads of death
 Operating Theater

Remove packing
Definitive Surgical Repair
Serial primary abdominal
closure

GOAL: Definitive surgical

procedure
Definitive Surgical Repair (2 – 8 days)
 Intensive Care (2)

Diuresis

GOAL:

Decrease fluid overload to

allow:
1.Definitive abdominal
Intensive Care Unit Stay
closure
(2 – 8 days)
2.Postoperative liberation
from ventilator
 SUMMARY

● Most preventable in hospital deaths from trauma are

due to uncontrolled hemorrhage and resultant
coagulopathy

● The successful resuscitation of the massively

bleeding and unstable trauma patient will depend on:
➢ effective trauma team leadership,
➢ identification of early trauma-related coagulopathy,
➢ correct decision-making in the emergency and
operating rooms
➢ prompt implementation of a DCR and a damage
control surgery.
 SUMMARY

● To increase the chances of survival :

➢ Surgically control hemorrhage
➢ Succesfully resuscitate the bleeding patient
➢ Adequately correct traumatic coagulopathy
 Major clinical
Type of resuscitation Intervention to trials focusing
strategy patients on the concepts

Permissive hypotension, To titrate and control the blood Dutton et al. 2002
Hypotensive pressure less than normal range Morrison et al 2011
resuscitation
To limit the volume of fluid to be Brown et al 2013
Restricted resuscitation, administered Schreiber et al. 2015
Controlled resuscitation
To restrict the fluid resuscitation Bickel et al. 2013
Delayed resuscitation until admission to the hospital Sampalis et al. 1997
(Early resuscitation is opposite term Turner et al. 2000
that means to initiate fluid
resuscitation from pre-hospital
setting)
 TRANSFUSI MASIF

1. Transfusi darah sebanyak volume darah tubuh

dalam waktu 24 jam.
2. Transfusi sel darah merah ≥ 4 kantong dalam waktu
1 jam.
3. Transfusi darah sebanyak 50% volume darah tubuh
dalam waktu 3 jam.

Capital Health
TRAUMA ASSOCIATED SEVERE
HEMORRHAGE

Nedim Y, J Trauma 2006 (60)

KORELASI TASH DENGAN
TRANSFUSI MASIF

Nedim Y, J Trauma 2006 (60))

ANALISA KUALITATIF TEG