Professional Documents
Culture Documents
Brčko 2015
Jelena Veličkovid
Vesna Bumbaširevid
Clinical center of Serbia
Belgrade
Trauma facts...
• Trauma is a disease
• Trauma is preventable,
predictable and treatable
• 5.8 million deaths each year
worldwide
• Trauma is a leading killer of
youth (5-44 years)
• 16% of disabilities caused by
trauma
• Huge economic impact
WHO report 2010.
More facts...
Definition Trauma
Damage
control
Scoring
Inflammation
Transfusion
Coagulation Transport
Consequent Combination
disability of 4 and 5
RATIONALE
• Classification and characterizing heterogenous trauma
patients
• Triage, resourcing
• Prognosis
• Quality care assessment
• Research
• Communication improvement
Hyperinflamation
Hypoinflammation
SIRS, MOF... MARS
CARS
Host response during polytrauma
ATLS textbook.2012
Complex ethiology-think about it!
1
+ 10
+ + 39
+ + 58
+ + 49
+ + + 85
+ + + + 98
PH<7.10 (OR=12.3)
T<34°C (OR=8.7)
ISS>25 (OR=7.7)
SBP<70 (OR=5.8) Cosgriff. J trauma 1997
Acidosis
• Poor tissue perfusion is the main contributor in trauma
patients
• Decreased cardiac output, hypoxia and anemia lead toward
cellular anaerobic metabolism and cause lactic acid
accumulation
• Resuscitation with normal saline induces hyperchloremic
acidosis
• Acidosis diminishes cardiac output leading to worse tissue
perfusion
• Aggravates coagulopathy
PH drop from 7.4 to 7.0 reduces the effectiveness of coagulation cascade
by 50-75%
Procoagulant drugs (rFVII) cannot work in acidotic environment
Hypothermia
• The greatest contributor to hypothermia are environmental
temperature, cold crystalloids and PRBCs
• Tissue hypoperfusion and anaerobic metabolism exhaust ATP
which is required for maintenance of normothermia.
• Hypothermia causes coagulopathies:
Coagulation cascade is temperature dependent
Relative thrombocyopenia by plateled sequestration and
dysfunction
• Induces shivering with further depletion of ATP and
progression of acidosis
Acute coagulopathy of trauma
• Present at admission in 25% of trauma patients
• 4 fold increase in mortality
PRIMARY – ENDOGENOUS
SECONDARY EVENTS
RESPONSE
Trauma Hemodilution
Shock Consumption
MacLeod JBA. Arch Surg 2008
Synonims
Tissue trauma
Shock with hypoperfusion
HYPOFIBRINOGENEMIA
HYPERFIBRINOLYSIS FIBRIN POLYMERISATION
DEFECTS
VIIIa Va Fibrin
D dimer
t-PA release
PC
Thrombomodulin low
TAFI
EPCR
Primary
hyperfibrinolysis
Haemorrhagic
shock
Depletion
INJURY WITH of clotting factors –
MULTIFOCAL BLEEDING fibrinogen and
BLOOD LOSS platelets
Hyperfibrinolysis • Haemodilution
LATE EVENT
• Resuscitation with
Diad of malfunction: non-clotting fluids
• hypothermia
• acidosis
Kozek-Langenecher.Min Anesth 2007
Vučelić D. Bilt Transfusiol 2012
Additional contributing factors
Hypocalcemia:
ionized Ca <1mmol/L
Anemia:
Hb < 100g/L
Preexisting
coagulation
disorders
Drug effects
COAGULOPATHY
Damage control
resuscitation
Haemostatic
resuscitation
Permissive hypotension
• Keep the blood pressure low enough to avoid
exsanguination while maintaining perfusion of end-
organs.
• Injection of a fluid will increase blood pressure:
Clot disruption
Hemoglobin and clot factor dilution
Hypothermia
Hematocrit ~ 30%
Coagulation factor activity > 30%
Platelet count > 80000 Miller T. Perioperative Medicine 2013.
Spinella PhC, Holcomb. Blood Reviews 2009.
Trauma blood packs
• Fibrinogen
• Cryoprecipitate
• PCC-Prothrombin complex concentrate
• F XIII
• F VIII, IX, vWF concentrate
R. Adams Cowley
Who coined the term and why?
The concept of “the golden hour” was a
marketing strategy by Dr. Cowley in
1963 in a letter to the Governor of
Maryland, the purpose of which was to
get ensure that police helicopters
would over-fly local hospitals and bring
severely injured pts to his Baltimore
Shock Trauma Centre.
…with no scientific evidence to support this
statement at the time!
Lockey. Resuscitation 2001.
Time matters...
Trimodal distribution of deaths in
trauma
. . .
Thank you