1. Unmanageable Bleeding in Trauma
Dr. Vimal Koshy Thomas MD (EM), DNB (EM)
Asst. Prof Emergency Medicine
JMMCH , Thrissur

2. Objectives ARE SHOCK PACKS BLIND AND WASTEFUL?
WOULD STANDARDIZED BLOOD LOSS ASSESMENT LEAD TO AN IDEAL TRANSFUSION?

3. No conflicts of interest

4. Unmanageable bleeding is leading cause of preventable death after Injury.
Coagulopathy will accompany such patients in more than 1/3 of cases.

5. Data at our centre

6. Patients requiring MTP in Trauma 2016-201833

7. Evolution of “Trauma induced coagulopathy”

8. Case Scenario
A 26-yr-old man, without significant medical history and weighting around 80 kg, was brought to the ED after being run over by car.
HR- 140/mt
BP-70 systolic
RR - 35/mt

9. Pls place a large bore IV….

10. Pathophysiology of TIC
Hypoperfusion
Activated Protein C
Catecholamines
Fibrinolysis and Factor degradation
Endothelial Changes
Platelet Dysfunction
Microparticles
Traumatic coagulopathy

11. Endothelial Involvement
Mediators of TIC
Mediators
Action
Reference
Activated Protein C
Fibrinolysis and Factor degradation
Brohi K et al. Acute traumatic coagulopathy: initiated by hypoperfusion: modulated through the protein C pathway? Ann Surg 2007
Endothelial Involvement
Syndecan-1
Johansson PI,et al.
A high admission syndecan-1 level, a marker of endothelial glycocalyx degradation, is associated with inflammation, protein C depletion, fibrinolysis, and increased mortality in trauma patients., Ann Surg 2011
Micro-particles
circulating endothelial-, erythrocyte-, and
leukocyte-derived microparticles
Matijevic Net al. Cellular microparticle and thrombogram
phenotypes in the Prospective Observational Multicenter Major Trauma Transfusion (PROMMTT) study: correlation with coagulopathy.
Thromb Res 2014; 134(3):652–8.
Platelets
Platelet dysfunction
Wohlauer MV et al. Early platelet dysfunction: an unrecognized
role in the acute coagulopathy of trauma. J Am Coll Surg 2012;214(5):
739–46.

12. Critical Role aPC in TIC
Injury
Hypoperfusion
Thrombomodulin
Thrombin
T/TM complex
Protein C
Activated
protein C

13. Increased Consumed PAi-1
High tPA aV
aVIII
PLASMIN
PLASMINOGEN
FORMATION
DEGRADATION
Explanation inadequate
CLOT

14. Is our Patient at risk for massive transfusion ?

15. Pre-emptive VS Goal directed strategies
Patient at risk for massive transfusion
Preemptive
1:1:1 transfusion
(PRBC: FFP: Platelet)
Using Clinical methods and resuscitative adjuncts
Goal directed
PT/PTT/ Fibrinogen/
Viscoelastic assays
Preemptive
1:1:1 transfusion
(PRBC: FFP: Platelet)
Using Clinical methods and resuscitative adjuncts
Should we discuss institution protocol?

16. Clinical Methods
ATLS- Advanced Trauma Life Support

17. Airway: Patent Talking , Patent.
Breathing: Sp02-90%, RR-35/mt B/L air entry present . Improved with high flow oxygen.
Circulation: FAST positive, BP-70 after 500 ml Crystalloids. HR- 130/mt.
Pelvic trauma , B/L femur fracture. Femoral vessel injury.
Disability: GCS-14/15 (Confused and Anxious)
Exposure: Warmer placed , hypothermia prevented.

18. “Blood on the Floor , Look for five More”

20. HR- 140/mt
BP-70 systolic
Low Pulse Pressure
RR - 35/mt
Low urine output
14/15
<-10mEq/l
Yes!!

21. Trauma patient….. Activated MTP
Blood sent for laboratory investigations
Routines, Cross Matching, PT/PTT

22. Pros and cons of clinical assessment
Pros: Helps guide resuscitation .
Cons: Underestimation of blood loss*

23. Resuscitation Adjuncts
Point of care Ultrasonography

24. Point of care Adjuncts pH Low Significant hypoperfusion probable 7.21
LAB
LEVEL
Usefulness in TIC
Our Patient pH
Low
Significant hypoperfusion probable
7.21
Base deficit / excess
Negative
<-10 meq/l
Hematocrit / Hemoglobin
Likely significant blood loss
29/ 9.2
Massive blood loss may produce only a slight decrease in initial hematocrit or hemoglobin concentration.*
*ATLS 10th Edition

25. Preemptive Strategy
….there was no difference in the primary endpoints of 24hr and 30 day mortality

26. A small trial conducted in Canada comparing 1:1:1 to laboratory-guided blood component therapy showed that achieving 1:1:1 despite concerted efforts was only achieved in 57% of the patients; moreover, it resulted in increased plasma wastage

27. Our trauma patient…
We started the patient on Preemptive strategy of blood transfusion
8 units PRBC, 8 platelet and 8 plasma units.
Following transfusion,
Vitals- BP-90/60 , Hr- 98/mt
However, 3 FFP were wasted.

28. ARE SHOCK PACKS BLIND AND WASTEFUL?
“….there is currently a lack of evidence to support empiric ratio-based blood product administration, including immediate platelet transfusion, for the seriously injured patient at risk for life-threatening hemorrhage”

29. Presumptive VS Goal directed strategies
Patient at risk for massive transfusion
Presumptive
1:1:1 transfusion
Using Clinical methods and resuscitative adjuncts
Goal directed
PT/PTT/ Fibrinogen/ D-dimer/
Viscoelastic Hemostatic assays
Goal directed
PT/PTT/ Fibrinogen/
Viscoelastic assays

30. Goal directed treatment of TIC
Standard Coagulation Assays-
PT/PTT/ Fibrinogen/ D-dimer
Viscoelastic Hemostatic assays-
TEG and ROTEM

31. Standard Coagulation Assays
TIC was initially defined by prolongation of the standard coagulation assays PTT and PT/International Normalized Ratio (INR).
PT represents factor VII
PTT represents factors XI, IX and VIII.
Both tests reflect the common pathway (factors X, V, and II).

32. Partial thromboplastin Time Prolonged Diagnostic of TIC
Lab
Level
Usefulness in TIC
Partial thromboplastin Time
Prolonged
Diagnostic of TIC
Prothrombin time/ International Normalized ratio

33. Commonly used Cutoffs Assay Cutoff Our trauma patient
Partial Thromboplastin time
>34-60 sec
>180 secs
Prothrombin time
>18 sec
>180 sec
INR
>
>10

34. Coagulation Assays Pros: Help Diagnosis of TIC. Cons:
Turn around time >= 60 minutes.
Coagulopathy are reported even normal ranges.
Does not give a ‘Snapshot’ of the patients current coagulopathy
Weak Guides to therapy.

35. Other tests
Fibrinogen deficit - Can predict TIC
D-dimer .

36. Visco-elastic Hemostatic Assays (VHA)
TEG and ROTEM
Assesses Multiple real time viscoelastic properties of coagulation.
thrombin generation,
platelet activity
fibrinogen cross-linking
providing a measurement of maximum clot strength
subsequent clot dissolution.

37. Against TEG
A recent Cochrane review suggested that there was insufficient evidence to recommend TEG-based transfusion guidelines as superior to established transfusion practice.

38. For TEG
50% increase in Survival in the thrombelastography (TEG) guided group was significantly higher than the conventional coagulation assays (CCA) group

39. Viscoelastic VS Preemptive MTP

40. WOULD STANDARDIZED BLOOD LOSS ASSESMENT LEAD TO AN IDEAL TRANSFUSION?
VHA > Standard coagulation tests
Resuscitation to be tailored to the individual patient in real time.
Coordinates the different modalities available for treatment.
Provides Dynamic management as the patient’s condition changes

41. Conclusion
Standard coagulation tests and functional viscoelastic assays are commonly used in the diagnosis and management of TIC.
Balanced resuscitation is the mainstay of TIC treatment, but precise ratios for empiric resuscitation and optimal monitoring protocols for transfusion practice are needed.

42. Thank You!!