Damage Control Resusc: toward an
EGDT for trauma
Lanny Littlejohn
CDR MC (FS/UMO/DMO) USN
NMCP Dept of Emergency Medicine
Cases to Consider
• 21 yo male with GSW to proximal thigh on the
Eastern Shore of Virginia
– Airevac from facility without surgical coverage
– 120 28 90/70, continued moderate bleeding,
becoming altered.
– ETA 25 min (helo just dispatched)
• 18 yo male with GSW to mid abdomen
– Hunting accident, shows up on your doorstep at a
small ED.
– 130 30 74/p
Plan of Attack
1
Historical highlights in trauma resuscitation
2
Changes and Current Practice at Trauma Ctrs
3
New Trends of Critical Importance
4
Future Directions in Trauma Resuscitation
Conclusion
Fluid Resucitation
Tourniquets
Terminology
• KIA
• DOW
• CFR
Killed in Action
Died of Wounds
Combination of above
• Levels of Care
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–
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I
II
III
IV
V
Resuscitative
Damage Control Surgery
Definitive Surgery in theatre
OCONUS, Landstuhl
Large MTF CONUS
Historical Background
WWI
WWII
Korea
“When a patient must wait for a considerable period,
elevation of his systolic blood pressure to
approximately 85 mmHg is all that is necessary…and
when profuse internal bleeding is present, it is
wasteful of time and blood to attempt to get the
Bleeding Control
patient’s blood pressureAggressive
up to normal.”
Permissive Hypotension
Hemostatic Resuscitation
Vietnam
ARDS
ACS
OIF
OEF
Cannon W, Fraser J, Cowell E. The Preventative Treatment of Wound Shock.
JAMA 1918:618-621
Tactical Combat Casualty Care
• Recognition that ATLS is inappropriate in the
combat setting
• Focused on 3 preventable causes of combat
death
• Combined Good Medicine with Good Tactics
• Divided the appropriate care into 3 phases
• Care under Fire (CUF)
• Tactical Field Care (TFC)
• Tactical Evacuation (TACEVAC)
TCCC in the 75th Ranger Regiment
Eliminating Preventable Death on the Battlefield, Arch Surg 2011
• All personnel trained in TCCC
• All training conducted with built-in TCCC
scenarios
• Substantial prehospital care provided by
nonmedical personnel
• 419 casualties, 32 fatalities
• None were from preventable causes in the
prehospital setting
The classic ATLS resuscitative
algorithm
• If vitals abnormal, give one bolus crystalloid
• Reassess, if still hypotensive or transiently
responds, give another
• PRBC’s after 2nd bolus of crystalloid
• Cont to monitor coags (PT/PTT/INR) until they
are 1.5 times normal and then begin correcting
• FFP, Cryoprecipitate, Platelets
• What is the problem with this approach?
Advanced Trauma Life Support, 8th
edition, the evidence for change
J Trauma 2008
• One safe way of providing initial assessment and
care
• “The ATLS course will not be at the sharp edge of
changes in trauma assessment, resuscitation,
and adoption of new technology.”
• Common baseline
• Still recommends crystalloid resuscitation but
allows for permissive hypotension.
Current Practice at Civilian
Trauma Centers
• In the last 5 years the approach to MT has undergone a
renaissance
• Of victims of trauma, 8-10% will receive a blood transfusion
• Of those…10% will need a massive transfusion
– What is a MT?
• What is Hemostatic Resuscitation (HR)?
• DCR?
• Survival benefit of high plasma:rbc appears to be primarily in
truncal hemorrhage
• Penetrating truncal trauma with noncompressible hemorrhage
is the most common cause of potentially preventable death in
US casualties
Current Practice of MT Protocol
• Activation by attending or fellow (Surg, Anesth,
EM, CC)
• Blood sample immed sent, bank sends
– 6u O PRBC
– 6u AB Plasma (some centers remains frozen)
•
•
•
•
Bank continues to send packs q 30 min w plt
Aggressive use of Cryo is emphasized (10u)
Calcium is also emphasized
If bleeding remains uncontrolled in the OR, FVIIa
is made available
•
•
•
•
Why is 1:1:1 theoretically better
than the old way?
Evidence is still flawed
Physiologic evidence is strong
Critically injured patients are losing whole blood
The coagulopathy of trauma is real and
multifactorial
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–
–
–
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Traumatic event itself (strongly inflammatory)
Consumption
Hypothermia
Acidosis
Iatrogenic (dilutional)
Overall, Coagulopathy is present in 25-38% and
assoc w 6 fold increase in mortality
Now for some random thoughts
• Which specialty is the initial resuscitative SME?
• The Problem with Trauma Research
– Why have we been going in circles for more than a
century
• Damage Control Resuscitation
– TXA
– Plasma
The Resuscitative Experts
• We are the resuscitative experts for all conditions
• We must know as much as the trauma surgeon in
the initial resuscitation of hemorrhagic shock
• A recent study reports that 25% of the US
population now lives farther from a trauma center
• 1981-1991: 66 centers had closed
• 1990-2005: 339 more centers had closed
• More and more trauma is being managed nonoperatively
Difficulties with Trauma Research
• Best evidence is based on animal research
• Human evidence is predominantly retrospective
and suffers many inherent biases
• Survival bias present in most HR studies
• Selection bias
• Academic bias
• Evidence follows a pyramid as it progresses
Ideas, editorials, opinions
Case reports, Case series, case-control
Cohort studies and then finally, RCTs
IV Crystalloid Resuscitation
• Still important component of ATLS
• Rationale for administering IVF’s in patients prior
to definitive control of hemorrhage has been
challenged repeatedly for almost a century
• No scientific evidence to support this
• Evidence does show that conventional
resuscitation exacerbates the underlying cellular
injury
• Hemorrhage related deaths primarily occur in
first 6 hours, thus early resusc needs more
precision
Damage Control Resuscitation
• Becoming standard of care in Trauma Centers
• Combines limited prehospital fluids with early
blood component resuscitation
• Goal is to prevent the lethal triad
• Outcomes can be improved if
– Hemorrhage is controlled early
– Permissive hypotension is followed for
penetrating trauma
– Hemostatic resuscitation vs Crystalloid
– TXA is given in appropriate settings
Is there good evidence?
• Hemorrhage control
– DO2 = CO X 1.34Hgb X SaO2 + 0.003paO2
• Permissive hypotension/Delayed Resuscitation
– Bickel, Immediate vs Delayed, NEJM, 1994
• Hemostatic Resuscitation
• Tranexamic Acid (TXA)
Tranexamic Acid
• Antifibrinolytic
– Inhibits plasminogen activation and plasmin
activity
– “Clot stabilizer”
– Fibrinolysis is huge in the Coagulopathy of
Trauma
• Thought similar to minimizing crystalloid resusc
to avoid disruption of soft thrombus
• Only recently being looked at for trauma
– CRASH 2 (Lancet, 2010)
– MATTERS (pending)
The Academic Bias
• CRASH2 showed a statistically significant
reduction in death due to bleeding w a NNT of 67
• RCT; n 20,211; 274 centers; 40 countries
• Criticisms were many, including the fact that the
benefit was overstated due to lack of
sophisticated trauma systems in many centers
• NO mention that one exclusion criteria were those
patients who would have clearly benefitted
• NO mention that the population at risk for death
was much smaller than the overall study
population
TXA makes sense
• Hyperfibrinolysis is an early component of
traumatic coagulopathy
• Thus, earlier use of TXA should decrease
bleeding
Tranexamic acid decreases mortality following wartime
injury: the Military Application of Tranexamic acid in
• MATTERS:
Trauma Emergency Resuscitation Study
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–
–
–
Retrospective
TXA group more severely injured
TXA group had lower mortality
TXA independently assoc with survival in MT
group
Some thoughts from the CoTCCC
• Majority of potentially survivable deaths are due
to hemorrhage in the combat setting
• 25% of the 6000 deaths in OIF and OEF had
potentially survivable injuries (1500)
• If benefit from TXA is indeed 1.5%
– 23 lives would have been saved
– Cost per life saved $5200
– One dose TXA = $39.12
Plasma as the primary fluid
• Problems with crystalloids
• Problems with colloids
• Plasma has several benefits over both
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–
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Expands plasma volume
Replaces lost coagulation proteins
Contains about 400 mg fibrinogen
50 times the buffering capacity of NS
Is not pro-inflammatory
Problem: FFP takes time to be thawed
Latest push now is the use of Freeze Dried Plama instead of
FFP in the combat setting. Time to reconstitute and
adminster is 5-10 min
Plasma Prehospital?
• Actually being done at Mayo Clinic and Memorial
Hermann Hospital in Houston
• Use of prehospital plasma achieves 1:1 at 30m
• Thus first plasma is received 131 m sooner
• In animal models, plasma improves survival over
hextend even without red cell transfusion
FDP (Lyophilized Plasma)
•
•
•
•
No cold chain requirements
Better flexibility as to where it can be given
Constituted when needed (approx 2 min)
Has been stored up to 30 years without altering
efficacy
Lessons Learned for Civilian
Practice
• 21 yo male shot in the groin by handgun on
Virginia’s Eastern Shore
• Stabilized in ED, dressing applied, 1 L LR given
for hypotension
• Bleeding resumes through bandages during flight
• Presents in trauma bay combative, hypotensive
again, bleeding uncontrolled from SFA
transection
• Admitted, repaired, dies from MOFS HD#3
Lessons Learned for Civilian
Practice
• 18 yo male with GSW to the Abdomen, brother
brings him in.
• You are at facility without surgical coverage.
• 120 92/76 28 98% Cool, sweaty, pale
• TXA
• Hemostatic Resuscitation
– Early plasma
– Permissive hypotension
Future Directions: These shock
conditions are not the same
• Septic shock char by:
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Closed
Dilated
High flow, low pressure
With infection as the primary etiology
• Hemorrhagic shock char by:
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–
–
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Open
Constricted
Low flow, low pressure
With hemorrhage as the primary etiology
Future Directions
• In sepsis we tended to under-resuscitate and
EGDT helped us to focus on specific endpoints
and early source control
• In trauma we tend to over-resuscitate and EGDT
for trauma is needed for:
– Source control
• Stop extremity hemorrhage (TQ, HA)
• Stabilize clot formation (TXA)
• Avoid the lethal triad (no crystalloids, hypothermia
prevention, early plasma protocols)
– Resuscitate to both specific hemodynamic and
coagulation system endpoints.
Predicting the need for MT
• Dente, J Trauma 2010
– Transpelvic and Multicavity wounds
– Combination of SBP<90 and Base deficit <-10
• Sihler, Chest 2009 : 4 independent predictors
– HR>105
– SBP<110
– pH<7.25
– Hct<32
• ABC Score (Assessment of Blood Consumption)
– Penetrating mechanism
– Hypotension
– Tachycardia
– Positive FAST
Once the need for MT is
predicted
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•
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•
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Control obvious severe hemorrhage
Primary assessment simultaneously with FAST
Activate protocol
Send basic labs and order CXR
TXA
Plasma (FDP?) and RBC’s
Tailor to TEG in major trauma centers
Thromboelastography
• R value: Reaction time
– Time until first evidence of clot is detected (initial
fibrin formation)
• K value
– The speed of clot formation (clot kinetics)
• Alpha Angle
– Rapidity of fibrin build up
• MA: Maximum Amplitude
– Strength of the clot
• Coagulation Index: takes into account all 4 values
Thromboelastography
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