Uncontrolled Hemorrhagic Trauma:
When all else fail to stop
Mohamed Saleh, MD
Department of Anesthesia and Intensive Care,
Ain-Shams University
Epidemiology of traumatic deaths
35
CNS injury
30
25
Exsanguination
15
CNS injury +
Exanguination
Airway compromise
10
MOF
20
5
Undetermined cause
0
Evans JA, van Wessem KJ, McDougall D, Lee KA, Lyons T, Balogh ZJ.
Epidemiology of traumatic deaths: comprehensive population-based assessment
World J Surg. 2010;34(1):158-63.
Trauma associated coagulopathy: the old theory
The lethal
triadcircle
The bloody
vicious
Acute coagulopathy of trauma: the new hypothesis
Systemic anticoagulation
Hyperfibrinolysis
Endothelium express
thrombomodulin
TM complexes with
Thrombin
Activation of protein
C pathway
Endothelium
releases tPA
coagulopathy
Hyper
fibrinolysis
Extrinsic Pathway is
inhibited
Systemic
anticoagulation
Fibrinogen
depletion
J R Army Med Corps. 2007; 153(4): 299-300.

‘Systematic approach to major trauma combining
the catastrophic bleeding, airway, breathing and
circulation (<C>ABC) paradigm with a series of
clinical techniques from point of wounding to
definitive treatment in order to minimize blood
loss, maximize tissue oxygenation and optimize
outcome’.
Armamentarium of
damage control
resuscitation
Permissive
hypotension
Early
prevention of
hypothermia,
acidosis
Rapid
control of
bleeding
Hemostatic
resuscitation
Permissive hypotension
Journal of the Intensive Care Society 2009; 10(2): 109-114
Effect of hypotensive resuscitation on survival rates
• Rationale
in trauma
patients
• Limitation
1. Penetrating
trauma – increase in survival rate.
2. Blunt trauma – no effect on survival rate.
Early prevention of hypothermia & acidosis
Conclusion: The prevention and timely correction, especially of
the combination acidosis plus hypothermia, is crucial for the
treatment of hemorrhagic coagulopathy.
Rapid control of bleeding
J R Army Med Corps. 2009; 155(4): 323-326.
Damage control surgery
Stage I — Rapid control of bleeding
Stage II — Delayed surgical repair
Hemostatic resuscitation
Massive
transfusion
protocol
Fresh whole
blood
transfusion
Vasopressin
Hemostatic
resuscitation
Optimum ratio
of blood
product
Recombinant
factor VIIa
Antifibrinolytic
POC
coagulation
assays
I - Massive transfusion protocol
I - Massive transfusion protocol
Conclusion: We have demonstrated that an exsanguination
protocol, delivered in an aggressive and predefined manner,
significantly reduces mortality as well as overall blood product
consumption.
I - Massive transfusion protocol
Conclusion: MTP was associated with a reduction in multi-organ
failure and infectious complications, as well as an increase in
ventilator free days. In addition, implementation of MTP was
followed by a dramatic reduction in development of abdominal
compartment syndrome and the incidence of open abdomen.
II - Fresh whole blood transfusion
Conclusion: In patients with trauma with hemorrhagic shock,
resuscitation strategies that include WFWB may improve 30day survival, and may be a result of less anticoagulants and
additives with WFWB use in this population.
III - Optimum ratio of blood products
Conclusion: In the civilian setting, plasma, platelets, and
cryoprecipitate products significantly increased 30-day
survival in trauma patients.
III - Optimum ratio of blood products
Shaz BH, Dente CJ, Nicholas J, MacLeod JB, Young
AN, Easley K, Ling Q, Harris RS, Hillyer CD.
Increased number of coagulation products
in relationship to red blood cell products
transfused improves mortality in trauma
patients.
Transfusion. 2010; 50(2): 493-500.
VI - POC coagulation assays:
role of thrombelastography
Conclusion: Thrombelastography was a more accurate indicator of
blood product requirements than PT, PTT, and INR. Thrombelastography enhanced by platelet count and hematocrit can guide
blood transfusion requirements.
V - Role of antifibrinolytic in patients with
hemorrhagic trauma
Lancet 2010; 376: 23–32
Conclusion: Early administration of tranexamic acid to
trauma patients with, or at risk of, significant bleeding
reduces the risk of death from hemorrhage with no
apparent increase in fatal or nonfatal vascular occlusive
events.
VI- Role of recombinant factor VIIa for
refractory traumatic hemorrhage
Conclusion: rFVIIa reduced blood product use but did not
affect mortality compared with placebo. Modern evidencebased trauma lowers mortality, paradoxically making
outcomes studies increasingly difficult.
VI- Role of recombinant factor VIIa for
refractory traumatic hemorrhage
Hauser CJ, Boffard K, Dutton R, Bernard GR, Croce MA, Holcomb JB, Leppaniemi A, Parr M, Vincent JL,
Tortella BJ, Dimsits J, Bouillon B; CONTROL Study Group.
Results of the CONTROL trial: efficacy and safety of recombinant activated Factor VII in the
management of refractory traumatic hemorrhage.
J Trauma. 2010; 69(3): 489-500.
2
VI- Role of recombinant factor VIIa for
refractory traumatic hemorrhage
Hauser CJ, Boffard K, Dutton R, Bernard GR, Croce MA, Holcomb JB, Leppaniemi A, Parr M, Vincent JL,
Tortella BJ, Dimsits J, Bouillon B; CONTROL Study Group.
Results of the CONTROL trial: efficacy and safety of recombinant activated Factor VII in the
management of refractory traumatic hemorrhage.
J Trauma. 2010; 69(3): 489-500.
2
VII - Role of vasopressin for hemorrhagic
trauma
World J Surg. 2011; 35(2): 430–439
Conclusion: Infusion of low-dose vasopressin could maintain
elevated serum vasopressin concentrations and decreased fluid
requirements after injury, and was associated with a possible early
survival advantage
Damage control
resuscitation
Conclusion
Permissive
hypotension
Early prevention of
hypothermia, acidosis
Hemostatic
resuscitation
Rapid
control of
bleeding
Hemostatic
resuscitation
Massive transfusion
protocol
Fresh whole blood
transfusion
Optimum ratio of
blood product
POC coagulation
assays
Antifibrinolytic
Recombinant factor
VIIa
Vasopressin
Frenzel T, Van Aken H, Westphal M
Curr Opin Anaesthesiol. 2008; 21(5): 657-663.
Thank you