EARLY CORRECTION OF
TRAUMA INDUCED COAGULOPATHY
CLOSE RATIO HEMOSTATIC
RESUSCITATION
Juan C Duchesne MD, FACS, FCCP, FCCM
Associate Professor of Surgery
Medical Director Tulane Surgical Intensive Care Unit
Section of Trauma/Critical Care Surgery/Anesthesia/Emergency Medicine
Spirit of Charity Hospital, New Orleans Louisiana
Inverse ratio 42:58 (Blunt: Penetrating)
4.9% severely injured with need of >10 u PRBC/24 hours
(Average Nation 1-2%) (War 5-7%)
Pre-DCR
The “Old” Face of Trauma Resuscitation
?
J TRAUMA 2010
How to Connect
the Silos?
HEMOSTATIC
RESUSCITATION
ED
OR
TICU
EFFECTIVE RESUSCITATION
J TRAUMA 2008
AMERICAN SURGEON 2011
60%
51.2%
50%
40%
30%
34.9%
28.3%
19.6%
20%
16.3%
8.7%
10%
0%
Overall
In OR
In T ICU
Mortality
1:1
1:4
J TRAUMA 2009
J TRAUMA 2010
PLASMA PROTECTION?
PLATELET PROTECTION?
12 Hrs.
24 Hrs.
MASSIVE TRANSFUSION
PROTOCOL
WHAT ABOUT rFVII?
$6,800
How We Do It
EARLY CORRECTION OF
TRAUMA INDUCED COAGULOPATHY
FOR ANY TRAUMA ACTIVATION
2 O Neg /LIQUID PLASMA
MCLNO Damage Control Resuscitation Protocol
6 PRBC: 6 FFP
6 PRBC: 6 FFP: 6 Platelets: 10 Cryoprecipitate
LVR
PRBC
Cryo
FFP
Platelets
Post- DCR
The New Face of Trauma Resuscitation
Case Scenario
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17 y/o AAM
Room 4 activation
Single GSW to epigastrium
Hypotensive, tachycardic, diaphoretic
Grade IV Shock
DCR activated based on above findings
Time in room 4: <10 minutes
Damage Control Laparotomy
• Initial impression: “what a bloody mess!”
• Severe Hemoperitoneum
• Plan: Damage control laparotomy (DCL)
with Damage Control Resuscitation
First Phase DCL:
Control of Bleeding and Contamination
•
•
•
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Gastrorhaphy, wedge resection X 2
Liver packing for Grade III injury
Distal pancreatectomy for Grade III injury
Splenectomy
Left nephrectomy for Grade IV injury
Peri-hepatic and retroperitoneal packing
Wound Vac placement
OR time: 88 min.
Grade III Pancreatic Injury
Early Hemostatic Resuscitation
•
•
•
•
•
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EBL 5L
PRBC 12u
FFP 15u
PLT 12u
LVR: 1.2L
UOP 220ml
83 minutes
Hospital Course
• POD#4
• POD#8
DC HOME!
Thanks!
CLOSE RATIO RESUSCITATION
Impact of Hemostatic Transfusion Ratios
on Morbidity and Mortality in Patients
with Severe
Intra-operative Hemorrhage:
An EAST Multi-Institutional Prospective
Trial
Juan C Duchesne MD, FACS, FCCP, FCCM
Associate Professor of Surgery
Medical Director Tulane Surgical Intensive Care Unit
Section of Trauma/Critical Care Surgery/Anesthesia
Juan C Duchesne MD, FACS, FCCP, FCCM
Associate Professor of Surgery
Medical Director Tulane Surgical Intensive Care Unit
Section of Trauma/Critical Care Surgery/Anesthesia
jduchesn@tulane.edu