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3/8/2021
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DISCLOSURES NONE
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3/8/2021
• Understand basic management principles
of hemorrhagic shock in ED trauma
patients
• Review management strategies for
controlling hemorrhage in non
OBJECTIVES compressible torso hemorrhage
• Review available heroic measures for
patients with severe bleeding and
hemorrhagic shock
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HEMORRHAGIC SHOCK
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BASIC MANAGEMENT PRINCIPLES
• Control of compressible bleeding sites
• Sutures where visible lacerations exist
• Fracture stabilization
• Tourniquet
• Identify non-compressible bleeding sites via imaging
• Optimal resuscitation strategy: blood is stronger than water
• Prevention of the “trauma triad”
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TRAUMA
TRIAD
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NON-COMPRESSIBLE TORSO
HEMORRHAGE
• High grade traumatic injury to pulmonary, solid abdominal organ, major vascular or pelvic
regions;
• PLUS hemodynamic instability or the need for immediate hemorrhage control
• Distribution of injury:
• Abdomen (~40%)
• Chest (~30%)
• Pelvis (~25%)
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NON-COMPRESSIBLE TORSO
HEMORRHAGE IDENTIFICATION
• Ultrasound
• Diagnostic peritoneal lavage
• CT scan
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IDENTIFICATION OF NON-COMPRESSIBLE
BLEEDING
• Bedside ultrasound: Thepocusatlas.com
• Fast and portable, immediately interpretable
• Accuracy is user dependent
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IDENTIFICATION OF NON COMPRESSIBLE
BLEEDING
• CT scan: for hemodynamically stable patients
• More sensitive for slower/lower volume bleeds
• Can be both diagnostic and therapeutic
• FACT (focused assessment with CT for trauma): reading method that
interprets pan-CT’s in three minutes.
• Developing protocols (PRESTO) for rapid CT→ IR in subset of hemodynamically
unstable patients
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DAMAGE CONTROL RESUSCITATION
• Refers to the concept of simultaneous hemostatic resuscitation, permissive hypotension and
damage control surgery
• Starts in the ED and continues through the OR and the ICU
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VOLUME RESUSCITATION
• Favor blood over crystalloid
• Data shows patients who receive >1.5L crystalloid resuscitation have worse
outcomes.
• Goal should be to reduce organ hypoperfusion while awaiting appropriate blood
products.
• Permissive hypotension, hypotensive resuscitation, etc.
• Both saline and lactated ringers have drawbacks in high volumes and no study has
demonstrated an overwhelming benefit of one versus the other.
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BLOOD
TRANSFUSION
• 1:1:1 (hemostatic) transfusion
strategy with higher ratios of
plasma and platelets than packed
PRBC’s
• Activate your institutions massive
transfusion protocol according to
institutional guidelines.
• Warmed volume resuscitation is
preferred when there is time and
capability
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ANTICOAGULATION REVERSAL
• Consider if there are any anticoagulants on board that require reversal- especially in the
elderly.
• Institutional availability
• Warfarin: 4PCCC (unactivated prothrombin complex concentrate) preferred over 3 PCC over FFP
plus vitamin k
• Direct thrombin inhibitors (dabigatran, rivaroxaban, apixaban, etc)
• Dabigatran: idarucizumab (Praxbind)> FEIBA (factor 8 inhibitor bypassing activity) > TXA (tranexamic
acid)
• Rivarox, apixaban, etc: andexanet alfa (AndexXa) > 4PCC >TXA
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TRANEXAMIC ACID
• Synthetic lysine analogue, antifibrinolytic drug that interferes with plasminogen binding to fribrin and prevents clot breakdown.
• CRASH-2 trial: adult trauma patients with significant bleeding, or risk of significant bleeding from traumatic injury randomized
into TXA infusion v. Placebo
• TXA dosing 1g loading dose over 10 minutes, then 1 gm over 8 hours
• Showed that early administration of TXA (within 3 hours) reduced the risk of death
• NO difference in number of patients requiring blood or in the number of RBC’s transfused.
• WOMAN trial: post partum hemorrhage
• Maybe a benefit if given early
• CRASH-3: TXA in ICH
• Fewer head injury related deaths if given within 3 hours.
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THROMBOELASTOGRAPHY
(TEG)
• TEG looks at the viscoelastic properties of clot
formation in real time.
• Can be used in the resus room while evaluating
patients response to resuscitation.
• Observational studies have demonstrated
effectiveness of protocols based on teg values
• Denver health TEG based transfusion strategy
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ROLE OF INTERVENTIONAL RADIOLOGY
• Transarterial embolization:
• Most common solid organ injury is the spleen.
• IR is now most preferred method of hemostasis for splenic bleed in hemodynamically stable patients.
• Can also be utilized for renal and other retroperitoneal injuries
• Pelvic trauma (after binding/fixation): bleeding usually from venous plexus bleeding or iliac vessel injury
• IR capabilities include embolization with coils and temporary occluders (gelfoam or slurries), balloon occlusion
devices, and stenting.
• Temporary balloon catheter ablation
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AORTIC OCCLUSION
• Traditionally obtained by cross clamping the aorta after thoracotomy in the ED or abdominal
access in the OR.
• High mortality with high morbidity
• Military anti shock trousers (mast) without proven benefit
• Intraperitoneal expanding foam
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REBOA
• Indicated for use in
abdominal or pelvic
hemorrhage to preserve
flow to brain and heart
• Less invasive than
thoracotomy
• Can be inserted in the
ED, IR suite, or OR.
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REBOA ZONES
• Zone I may be used as a “physiologic bridge” to
the OR in abdominal hemorrhage
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REBOA: COMING TO AN ER NEAR YOU?
• Ongoing preclinical trials
• 2018 ACEP and ACS COT joint statement:
• “no current, high-grade evidence clearly demonstrates REBOA improves outcomes or survival compared to standard
treatment of severe hemorrhage.”
• Reboa is less invasive than traditional methods, but in skilled hands can be useful and acute care surgeons can learn and
safely place reboa after a formal training course
• EMCC with additional REBOA training OR EM with advanced military training can place only if vascular or ACS available
• REBOA should be placed by acute care surgeon or interventional radiologist and ACS should be immediately available for
long term management of hemorrhage
• Updated guidelines recommend that there is still no good data supporting its use but if you plan to do so, a
multidisciplinary team needs to be in place.
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TAKE HOME POINTS
• Avoid the trauma triad
• Give blood early and always with plasma and platelets
• Utilize appropriate imaging for suspected ongoing hemorrhage, with IR on call for assistance
• If you have TEG, use it
• Know your reversal and “rescue” agents
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THANK YOU
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