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polytrauma

J. Duranteau
Department of Anaesthesia and Intensive Care
Hôpitaux universitaires Paris-Sud
Severe Trauma

Worldwide leading cause of death patients < 44 years

Early mortality is usually due to uncontrolled haemorrhage

Late mortality and disability is due to


brain injury and multiple organ failure

Many survivors face long rehabilitation and difficult


reintegration into their previous life
Severe trauma

STOP the bleeding


1 Time between injury and operation has to be minimized
Don’t lose time
Damage control surgery and resuscitation

Damage control surgery and resuscitation

The goal is to provide only interventions necessary to


control hemorrhage to focus on reestablishing a
survivable physiologic status

This strategy begins from the scene to the emergency room and
continues through the OR and into the ICU

Recent terrorist attacks imply that we master the damage control


resuscitation
Severe trauma

Efficient trauma system

Effective pre-hospital providers and protocols

Designated trauma centers

Trained and available trauma specialists and nurses

Communication and coordination

Trauma registry
Multidisciplinary task force
Research program

Rehabilitations facilities
✓ Comparative analysis of data from the Royal London Hospital (RLH) trauma registry and Trauma
Audit and Research Network (England and Wales), 2000–2005
✓ Institution of a specialist trauma service and performance improvement programme

✓ ISS >15: 3·4 additional survivors per 100 trauma


✓ ISS >24: 11 additional survivors per 100 trauma

Davenport RA et al. British Journal of Surgery


2010; 97: 109–117
Red Flag

▪ Derivaderivation (n=4339) and validation (n=3606) cohorts


▪ The Red Flag alert was triggered by the presence of any combination of at least two
criteria
0
▪ Sensitivity 75% [72-79], specificity 79% [77-80], and area under the ROC curve 0.83
[0.81-0.84] to identifying blunt trauma patients with high risk of severe haemorrhage.
Assessment and initial management

Management of respiratory and


hemodynamic failures

EFAST (extended focused assessment with sonography for


trauma) to augment clinical assessment

Major haemorrhage protocol activation


Peripheral + Central intravenous access + Arterial line
Fluid + Vasopressor resuscitation
Transfusion protocol

Tourniquet - Pelvic binders

whole-body CT
Senior physician Nurse

Nurse

Junior physician
Extended focused assessment sonography for trauma (eFAST)
Assessment and initial
management of severe trauma

Hemodynamic instability Hemodynamic stability

Hemodynamic instability not Hemodynamic instability


responding to resuscitation responding to resuscitation

Interventional Damage control


radiology surgery

Whole-body CT
Severe trauma

STOP the bleeding


1 Time between injury and operation has to be minimized
Don’t lose time

Avoid to exacerbate the bleeding


▪ Permissive Hypotension
2 ▪ Low volume fluid resuscitation
▪ Early treatment of coagulopathy
The European guideline on management of major bleeding and coagulopathy
following trauma: Fourth edition

Rossaint R et al. Critical Care 2016

Time between injury and operation has to be minimised

The concept of low volume fluid resuscitation and


“permissive hypotension” avoids the adverse effects of early
aggressive resuscitation while maintaining a level of tissue
perfusion that, although lower than normal, is adequate for
short periods

Target SAP 80-90 mmHg until major bleeding has been stopped

MAP ≥80 mmHg in patients with severe TBI (GCS ≤8)


Fluid resuscitation in trauma

Low volume fluid resuscitation ≠ No fluid resuscitation

Fluid resuscitation must be limited to what is strictly necessary to


achieve recommended arterial pressure target

Fluid resuscitation alone ≠ Fluid resuscitation and vasopressor


Fluid resuscitation in trauma

Low volume fluid resuscitation ≠ No fluid resuscitation

Fluid resuscitation must be limited to what is strictly necessary to


achieve recommended arterial pressure target

Fluid resuscitation alone ≠ Fluid resuscitation and vasopressor

▪ 250 mL of fluid if SAP <80 mm Hg


▪ Additional 250-mL boluses if sustained
hypotension (SBP of <80 mm Hg)
The European guideline on management of major bleeding and coagulopathy
following trauma: Fourth edition

Rossaint R et al. Critical Care 2016

Use of a restricted volume replacement strategy to achieve target blood


pressure until bleeding can be controlled

Fluid therapy using isotonic crystalloid solutions should be initiated in


the hypotensive bleeding trauma patient

Use of colloids must be restricted due to the adverse effects on


haemostasis

In the presence of life-threatening hypotension,


administration of vasopressors in addition to fluids to maintain
target arterial pressure
A controlled resuscitation strategy is feasible and safe in hypotensive
trauma patients: Results of a prospective randomized pilot trial

Schreiber MA et al. J Trauma


✓ Multicenter randomized trial. Out-of-hospital SAP <90 mm Hg. Acute Care Surg (2015)
✓ Controlled resuscitation group: 250 mL of fluid if they had no radial pulse or
an SAP < 70 mm Hg and additional 250-mL boluses to maintain a radial pulse
or an SBP ≥70 mm Hg.
✓ Standart Resuscitation group: 2 L initially and additional fluid as needed to
maintain an SBP≥110 mm Hg.
✓ The crystalloid protocol was maintained until hemorrhage control or 2 hours
after hospital arrival.

The median (thick solid line),


mean (diamond) and 25th and
75th percentiles

1.0 ± 1.5 l 2.0 ± 1.4 l


A controlled resuscitation strategy is feasible and safe in hypotensive
trauma patients: Results of a prospective randomized pilot trial

Fluid and Blood Resuscitation in Liters Out-of-hospital time Out-of-hospital time


41 ± 14 min 43 ± 17 min

Schreiber MA et al. J Trauma


Acute Care Surg (2015)
A Paradigm Shift in Trauma Resuscitation Evaluation of
Evolving Massive Transfusion Practices

Massives transfusion practices


▪ % of RBCs transfused within 6 hours increased from 80%
in 2005 to 88% in 2011
▪ % of FFP transfused within 6 hours increased from 74% in
2005 to 87% in 2011
Median total ▪ Shift toward a reduced crystalloid volume and more
24-hour crystalloid plasma-based MT practices
volume = 13 L in 2005

Median total
24-hour crystalloid
volume = 4 L in 2011

ME Kutcher et al. JAMA Surg. 2013


▪ Severe hemorrhage (SH) = transfusion of at least 4 units
of packed RBCs in the first 6 hrs and/or death related to
uncontrolled bleeding in the first 24 hrs following injury. SH CL p
▪ Trauma patients without SH = control patients (CL)
N: 755 N: 5647
ISS 33 [20-43] 11 [5-20] < 0.001
Minimal systolic BPprehosp (mmHg) 80 [60-99] 118 [102-130] < 0.001
Maximal HRprehosp (bpm) 106 [80-126] 90 [80-106] 0.056

Shock indexprehosp 1.2 [0.8-1.5] 0.8 [0.6-0.95] < 0.001

FVprehosp total (mL) 1500 [1000-2000] 500 [500-1000] < 0.001

FVprehosp crystalloids (mL) 1000 [500–1500] 500 [500-1000] < 0.001


FVprehosp colloids (mL) 0 [0-500] 0 [0-0] < 0.001

Time to hospital admission (min) 80 [60-104] 71 [53-97] < 0.001

HR at admission (bpm) 102 [80-120] 86 [74-100] < 0.001

Systolic BP at admission (mmHg) 96 [74-117] 129 [114-143] < 0.001


Diastolic BP at admission (mmHg) 76 [66-87] 56 [42-72] < 0.001

Shock indexhosp 1 [0.75-1.4] 0.7 [0.6-0.8] < 0.001

Lactatehosp (mmol/L) 4.3 [3-8] 2.8 [1-3] < 0.001

ICU mortality (n, %) 275 (37) 364 (7) < 0.001


Fluid resuscitation in trauma

Low volume fluid resuscitation ≠ No fluid resuscitation

Fluid resuscitation must be limited to what is strictly necessary to


achieve recommended arterial pressure target

Fluid resuscitation alone ≠ Fluid resuscitation and vasopressor


Venous return

Venous transmural pressure No venous return Venous return increases

PRA

Unstressed blood volume Stressed blood volume

Non circulatory blood volume Circulatory blood volume

Total intravascular volume


Impact of epinephrine and norepinephrine on two
dynamic indices in a porcine hemorrhagic shock model

▪ Prospective, physiologic, animal study, in deeply sedated and


mechanically ventilated pigs.
▪ Evaluation of the impact of the administration of catecholamines Giraud R. et al. J Trauma Acute
on Pulse pressure variations (PPVs), stroke volume variations Care Surg. 2014
(SVVs), and inferior vena cava flow (IVCF).

Pre-NE NE H Pre-NE H NE Pre-NE NE H Pre-NE H NE


Effect of norepinephrine during resuscitation
of uncontrolled hemorrhagic shock in mice

Harrois et al. Anesthesiology 2015

Blood loss at T90 (µL)


Effect of norepinephrine during resuscitation
of uncontrolled hemorrhagic shock in mice

Harrois et al. Anesthesiology 2015


Villous perfused density
in each group (% ± SEM)
Fluid resuscitation in trauma

Low volume fluid resuscitation ≠ No fluid resuscitation

Fluid resuscitation must be limited to what is strictly necessary to


achieve recommended arterial pressure target

Fluid resuscitation alone ≠ Fluid resuscitation and vasopressor

No response after 0.5 L of fluid resuscitation: start


norepinephrine (0.1 µg/kg/min)
Severe trauma

STOP the bleeding


1 Time between injury and operation has to be minimized
Don’t lose time

Avoid to exacerbate the bleeding


▪ Permissive Hypotension
2 ▪ Low volume fluid resuscitation
▪ Early treatment of coagulopathy

Restore efficient coagulation


3 Goal-directed transfusion guided by standard laboratory
coagulation values and viscoelastic tests
Trauma-induced coagulopathy

Trauma-induced coagulopathy is able to exacerbate bleeding, thus


creating a lethal vicious circle

Trauma-induced coagulopathy is present in about 25-35% of trauma patients


at their admission and impact signicantly on morbidity and mortality

Fast and accurate diagnostic of coagulopathy is a key element


for achieving adequate hemostatic resuscitation
Cause of trauma-induced coagulopathy

Coagulation activation
▪ Procoagulants in the systemic circulation
▪ Impairment of endogenous anticoagulant
activity
▪ Thrombin generation in the systemic
circulation

Hyperfibrinolysis
▪ Acute release of tissue-plasminogen activator
(t-PA)-induced hyperfibrinolysis
▪ Coagulation activation-induced fibrinolysis

Consumption coagulopathy

Trauma-induced coagulopathy
Cause of trauma-induced coagulopathy
The European guideline on management of major bleeding and
coagulopathy following trauma: Fourth edition

Rossaint R et al. Critical Care 2016

Early and repeated monitoring of coagulation, using either a traditional


laboratory determination and/or a viscoelastic method

Goal-directed strategy guided by standard laboratory coagulation


values and/or viscoelastic tests

Plasma and red blood cells Fibrinogen concentrate


in a plasma-RBC ratio of at 1 2 and red blood cells
least 1:2

Fibrinogen concentrate if significant bleeding


with functional fibrinogen deficit or a plasma
fibrinogen <1.5 g/l
The European guideline on management of major bleeding and
coagulopathy following trauma: Fourth edition

Rossaint R et al. Critical Care 2016

Early and repeated monitoring of coagulation, using either a traditional


laboratory determination [prothrombin time (PT), activated partial
thromboplastin time (APTT) platelet counts and fibrinogen] and/or a
viscoelastic method

Goal-directed strategy guided by standard laboratory coagulation


values and/or viscoelastic tests

Packs of specified ratio of RBC, FFP and platelets and goal-


directed approach
Code Red Massive Haemorrhage Policy
at the Royal London Hospital
Targeting blood products transfusion in trauma: what
is the role of thromboelastography?
S. Figueiredo et al. Minerva 2017
Goal-directed Hemostatic Resuscitation of Trauma-induced
Coagulopathy

✓ Randomized clinical trial (RCT) to test the hypothesis that an MTP goal directed
by TEG improves survival compared with an MTP guided by conventional
coagulation assays (CCA). Gonzalez E.
et al. Injury, Ann Surg 2015
✓ After MTP activation, patients were randomized to be managed either by an MTP
goal directed by TEG or by CCA

CCA group in the first 2 hours of resuscitation


✓ Similar number of RBC units as the TEG patients
[CCA: 5.0 (2 – 11) vs TEG: 4.5 (2 – 8)]
✓ but more plasma units [CCA: 2.0 (0 – 4), TEG: 0.0 (0–3)],
and more platelets units [CCA: 0.0 (0–1), TEG: 0.0 (0–0)]
Multicenter randomized trial of 680 severely injured patients
and were predicted to require massive transfusion

1:1:1 group: 6 U of plasma, 1 dose of platelets (a pool of 6 U on


average), and 6 U of RBCs.
1:1:2 group: 3 U of plasma, 0 doses of platelets, and 6 U of RBCs.
Second container included 3 U of plasma, 1 dose of platelets (a pool JB. Holcomb et al. JAMA 2015
of 6 U on average), and 6 U of RBCs.
Multicenter randomized trial of 680 severely injured patients
and were predicted to require massive transfusion

✓ Anatomic hemostasis in the OR = objective


assessment by the surgeon indicating that
bleeding within the surgical field was
controlled
Exsanguination, which was the predominant cause of ✓ Anatomic hemostasis in the interventional
death within the first 24 hours, was significantly radiology suite = no blush after embolization
decreased in the 1:1:1 group vs 1:1:2 group
(9.2% vs 14.6%; P = .03)

JB. Holcomb et al. JAMA 2015


The European guideline on management of major bleeding and
coagulopathy following trauma: Fourth edition

Rossaint R et al. Critical Care 2016

Early and repeated monitoring of coagulation, using either a traditional


laboratory determination and/or a viscoelastic method

Goal-directed strategy guided by standard laboratory coagulation


values and/or viscoelastic tests

Plasma and red blood cells Fibrinogen concentrate


in a plasma-RBC ratio of at 1 2 and red blood cells
least 1:2

Fibrinogen concentrate if significant bleeding


with functional fibrinogen deficit or a plasma
fibrinogen <1.5 g/l
Reversal of trauma-induced coagulopathy using rst-line coagulation factor
concentrates or fresh frozen plasma (RETIC): a single-centre, parallel-group, open-
label, randomised trial

▪ Single-centre, parallel-group, open-label, randomised trial was done at the Level 1


Trauma Center P. Innerhofer et al. Lancet
▪ FFP (15 mL/kg) or CFC (coagulation factor concentrates) (primarily fibrinogen
concentrate [50 mg/kg])
Haematol 2017
▪ The primary clinical endpoint was multiple organ failure
Reversal of trauma-induced coagulopathy using rst-line coagulation factor
concentrates or fresh frozen plasma (RETIC): a single-centre, parallel-group, open-
label, randomised trial

▪ Single-centre, parallel-group, open-label, randomised trial was done at the Level 1


Trauma Center P. Innerhofer et al. Lancet
▪ FFP (15 mL/kg) or CFC (coagulation factor concentrates) (primarily fibrinogen
concentrate [50 mg/kg])
Haematol 2017
▪ The primary clinical endpoint was multiple organ failure

The study was terminated early for futility and safety reasons because of the high
proportion of patients in the FFP group who required rescue therapy compared with
those in the CFC group (23 [52%] in the FFP group vs 2 [4%] in the CFC group

Treatment failure was registered if even double-dose study drug administration did not
correct ROTEM pathology or if coagulopathic bleeding persisted at
borderline ROTEM measurements
Reversal of trauma-induced coagulopathy using rst-line coagulation factor
concentrates or fresh frozen plasma (RETIC): a single-centre, parallel-group,
open-label, randomised trial

Bleeding score
▪ 0: no substantial bleeding
▪ 1: injury-related normal bleeding with visible
clots
▪ 2: diffuse microvascular bleeding from wound
and catheter insertion sites
▪ 3: massive bleeding with transfusion of >3 U
red blood cells/h

P. Innerhofer et al. Lancet


Haematol 2017

Massive transfusion
13 [30%] in the FFP group
6 [12%] in the CFC group
OR 3·04 [0·95–10·87], p=0·042)
The European guideline on management of major bleeding and
coagulopathy following trauma: Fourth edition

Rossaint R et al. Critical Care 2016


Fibrinogen & cryoprecipitate

Treatment with fibrinogen concentrate or cryoprecipitate if significant bleeding


is accompanied by viscoelastic signs of a functional fibrinogen deficit or a
plasma fibrinogen <1.5 g/l

We suggest an initial fibrinogen supplementation of 3-4 g


This is equivalent to 15-20 single donor units of cryoprecipitate or
3-4 g fibrinogen concentrate

Repeat doses must be guided by viscoelastic monitoring and


laboratory assessment of fibrinogen levels
The European guideline on management of major bleeding and
coagulopathy following trauma: Fourth edition

Rossaint R et al. Critical Care 2016

We recommend that tranexamic acid be administered as early as


possible to the trauma patient who is bleeding or at risk of
significant hemorrhage
(1 g, followed by an IV infusion of 1 g over 8 h)

We recommend that tranexamic acid be administered to


the bleeding trauma patient within 3 h after injury
Severe trauma

STOP the bleeding


1 Time between injury and operation has to be minimized
Don’t lose time

Avoid to exacerbate the bleeding


▪ Permissive Hypotension
2 ▪ Low volume fluid resuscitation
▪ Early treatment of coagulopathy

Restore efficient coagulation


3 Goal-directed transfusion guided by standard laboratory
coagulation values and viscoelastic tests

4 Manage the combined life-threatening injuries


Severe trauma with acute brain injury

Brain injury

Pre-HC ER OR ICU

Transcranial
Doppler

PIC
PbtO2
SvjO2

Damage control strategy: restore normal physiology


rather than normal anatomy
Damage control surgery and resuscitation

Traumatic Bain injury


+
Orthopedic surgery

Pre-HC ER OR ICU OR ICU

« The goal of damage control is to restore normal physiology


rather than normal anatomy »
Severe trauma

STOP the bleeding


1 Time between injury and operation has to be minimized
Don’t lose time

Avoid to exacerbate the bleeding


▪ Permissive Hypotension
2 ▪ Low volume fluid resuscitation
▪ Early treatment of coagulopathy

Restore efficient coagulation


3 Goal-directed transfusion guided by standard laboratory
coagulation values and viscoelastic tests

4 Manage the combined life-threatening injuries

5 Training - Evaluation - Research


B. Vigué
C. Laplace Department of Anaesthesia and Intensive Care
C. Ract Hôpitaux Universitaires Paris-Sud
P.E. Leblanc Bicêtre Hospital
G. Cheisson
A. Harrois
S. Figueiredo
S. Hamada
A. Rodrigues
G. Dubreuil
J. Pochard
V. Tarazona
« Change starts with one person standing up
and saying « no more »»