2. Uncontrolled Hemorrhagic Trauma: When all else fail to stop Mohamed Saleh, MD Department of Anesthesia and Intensive Care, Ain-Shams University

3. 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. Epidemiology of traumatic deaths

4. Trauma associated coagulopathy: the old theory The bloody vicious circleThe lethal triad

5. coagulopathy Systemic anticoagulation Hyperfibrinolysis Acute coagulopathy of trauma: the new hypothesis Endothelium express thrombomodulin TM complexes with Thrombin Activation of protein C pathway Extrinsic Pathway is inhibited Systemic anticoagulation Endothelium releases tPA Hyper fibrinolysis Fibrinogen depletion

7. J R Army Med Corps. 2007; 153(4): 299-300. ‘Systematic approach to major trauma combining the catastrophic bleeding, airway, breathing and circulation ( 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’.

8. Armamentarium of damage control resuscitation Permissive hypotension Early prevention of hypothermia, acidosis Rapid control of bleeding Hemostatic resuscitation

9. Permissive hypotension Rationale Limitation Journal of the Intensive Care Society 2009; 10(2): 109-114 Effect of hypotensive resuscitation on survival rates in trauma patients 1.Penetrating trauma – increase in survival rate. 2. Blunt trauma – no effect on survival rate.

10. 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.

11. Rapid control of bleeding J R Army Med Corps. 2009; 155(4): 323-326. Stage I — Rapid control of bleeding Stage II — Delayed surgical repair Damage control surgery

12. Hemostatic resuscitation Massive transfusion protocol Fresh whole blood transfusion Optimum ratio of blood product POC coagulation assays Antifibrinolytic Recombinant factor VIIa Vasopressin Hemostatic resuscitation

13. I - Massive transfusion protocol

15. 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

16. 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. I - Massive transfusion protocol

17. Conclusion: In patients with trauma with hemorrhagic shock, resuscitation strategies that include WFWB may improve 30- day survival, and may be a result of less anticoagulants and additives with WFWB use in this population. II - Fresh whole blood transfusion

18. III - Optimum ratio of blood products Conclusion: In the civilian setting, plasma, platelets, and cryoprecipitate products significantly increased 30-day survival in trauma patients.

19. 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. III - Optimum ratio of blood products

20. Conclusion: Thrombelastography was a more accurate indicator of blood product requirements than PT, PTT, and INR. Thromb- elastography enhanced by platelet count and hematocrit can guide blood transfusion requirements. VI - POC coagulation assays: role of thrombelastography

21. 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. V - Role of antifibrinolytic in patients with hemorrhagic trauma

22. Conclusion: rFVIIa reduced blood product use but did not affect mortality compared with placebo. Modern evidence- based trauma lowers mortality, paradoxically making outcomes studies increasingly difficult. VI- Role of recombinant factor VIIa for refractory traumatic hemorrhage

23. 2 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. VI- Role of recombinant factor VIIa for refractory traumatic hemorrhage

24. 2 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. VI- Role of recombinant factor VIIa for refractory traumatic hemorrhage

25. 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 VII - Role of vasopressin for hemorrhagic trauma

26. Damage control resuscitation Permissive hypotension Early prevention of hypothermia, acidosis 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 Hemostatic resuscitation Conclusion

28. Thank you