HAEMORRHAGE CONTROL RICARDO MATOS / ANNE WEAVER

Haemorrhage control: When to go to the operation room? (Luke Leenen)

Trauma is dynamic and constant evaluation with decision-making are the norms. You need to check, check and check the patient again.

Physiology is key. Imaging only aids this.

The role of damage control surgery is NOT to restore anatomy.

Phase 1 – damage control (abbreviated surgery), life saving only. Control haemorrhage/contamination, pack, temporary closure. Physiology leads the decision making in theatre.

Phase 2 – restoration of physiology on ICU; temperature, acidosis, coagulopathy

Phase 3 – definitive surgery. When not to go when hypothermic and uncorrected coagulopathy.

Phase 4 – reconstructive surgery (can be months later)

 

The Impact of an Intensivist-Model ICU on Trauma-Related Mortality

“It’s Parallel Universes”: An Analysis of Communication Between Surgeons and Intensivists.

 

Haemorrhage control: When to go to the angiography suite? (Sophie Hamada)

The evolution of a purpose designed hybrid trauma operating room from the trauma service perspective: the RAPTOR (Resuscitation with Angiography Percutaneous Treatments and Operative Resuscitations).

Damage control radiology – http://bja.oxfordjournals.org/content/113/2/250.abstract

Embolization for multicompartmental bleeding in patients in hemodynamically unstable condition: prognostic factors and outcome.

Management of penetrating trauma (Pierre Carli)

MARCHE – Massive bleeding control, airway, respiration, circulation, head, evacuation

Triad of death – coagulopathy, acidosis and hypothermia

Damage control resuscitation – ncbi.nlm.nih.gov/pmc/articles/P…

Practical translation of hemorrhage control techniques to the civilian trauma scene.

Transfusion strategies in severe trauma (Anne Weaver)

Bart’s and the London NHS Trust (Home of London Air Ambulance) Trauma Transfusion Protocols:

These are the a selection of papers of trials/studies that have guided current practice and some more underway to guide future therapies.

The pathophysiology of trauma-induced coagulopathy.

Transfusion of Plasma, Platelets, and Red Blood Cells in a 1:1:1 vs a 1:1:2 Ratio and Mortality in Patients With Severe Trauma: The PROPPR Randomized Clinical Trial

Karim Brohi on TXA – http://intensivecarenetwork.com/karim-brohi-on-tranexamic-acid-in-trauma/

Early fibrinogen trial – http://efit1trial.co.uk/

RePHILL (Resuscitation with Pre-Hospital Blood Products)

CRYOSTAT: A feasibility study for a multicentre, randomised controlled trial evaluating the effects of early administration of cryoprecipitate in major traumatic haemorrhage

iTACTIC – RCT looking at viscoelastic haemostats assays versus empiric transfusion protocols

Stopping trauma-induced coagulopathy (Dietmar Fries)

Fibrinogen levels during trauma hemorrhage, response to replacement therapy, and association with patient outcomes.

FINTIC trial- Fibrinogen Concentrate (FGTW) in Trauma Patients, Presumed to Bleed (FI in TIC)

 

Haemorrhage associated with direct/novel oral anticoagulants (Giuseppe Citero)

There is very little published data and working clinical knowledge of NOACs in trauma

Reversal of rivaroxaban and dabigatran by prothrombin complex concentrate: a randomized, placebo-controlled, crossover study in healthy subjects.

The European guideline on management of major bleeding and coagulopathy following trauma: fourth edition

Reversal of anticoagulants: an overview of current developments

Management of direct oral anticoagulants-associated bleeding in the trauma patient.

 

INTERACTIVE SESSION LUCIANO GATTINONI

Radiology quiz (Sophie Hamada)

Transcranial Doppler after traumatic brain injury: is there a role? ncbi.nlm.nih.gov/pubmed/2453165

Transcranial Doppler pulsatility index: what it is and what it isn’t – http://www.ncbi.nlm.nih.gov/pubmed/22311229

U/S of ONSD for detection of raised intracranial pressure: a systematic review and meta-analysis – ncbi.nlm.nih.gov/pubmed/21505900

The effectiveness of prophylactic inferior vena cava filters in trauma patients: a systematic review and meta-analysis – http://www.ncbi.nlm.nih.gov/pubmed/24195920

ICU MANAGEMENT OF SEVERE TRAUMA JOÃO GOUVEIA / JACQUES DURANTEAU

Severe traumatic brain injury (Giuseppe Citerio)

The GCS is still being used to classify TBI BUT it is a very heterogenous group of conditions. Reducing GCS at scene correlates very well with mortality

TBI severity ratio of hospitalised pts is changing – 90% are mild

Causes of TBI have also changed – rising car crashes in Asia and India. UK/US/Australia has reducing numbers of car crashes causing TBI and falls increasing numbers.

Older pts being admitted – changing TBI population median age has increased by a decade in last 10-15 years.

Recommendations on the use of EEG monitoring in critically ill patients: consensus statement from the neurointensive care section of the ESICM –http://icmjournal.esicm.org/journals/abstract.html?v=39&j=134&i=8&a=2938_10.1007_s00134-013-2938-4&doi

Consensus summary statement of the International Multidisciplinary Consensus Conference on Multimodality Monitoring in Neurocritical Care –http://www.esicm.org/admin/lib/ckfinder/userfiles/files/NCC_Consensus_ICM_09_2014.pdf

Spinal cord injury (Geert Meyfroidt)

Monitoring of spinal cord perfusion pressure in acute spinal cord injury: initial findings of the injured spinal cord pressure evaluation study*

Early versus Delayed Decompression for Traumatic Cervical Spinal Cord Injury: Results of the Surgical Timing in Acute Spinal Cord Injury Study (STASCIS) – http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0032037

Cochrane review – Steroids for acute spinal cord injury

Conclusion

• Early surgery and decompression
• Steroids not recommended original trials flawed (NASCIS 2 and 3 trials)
• Supportive therapy according to level

geert.meyfroidt@uzleuven.be

 

Severe chest trauma (John Laffey)

ANZCOR Guideline 11.10.1 Management of Cardiac Arrest due to Trauma

Surgical intervention rarely needed in chest trauma (besides chest tube)

Role of surgical fixation for flail segments – poor evidence

Pulmonary contusion – common

Indication to fix ribs is uncertain unless thoracotomy for other reasons.

RibScore: A novel radiographic score based on fracture pattern that predicts pneumonia, RF, & trachy – ncbi.nlm.nih.gov/pubmed/26683395

NIV may have a role but only used in 5% of patients- Safety and efficacy of noninvasive ventilation in patients with blunt chest trauma: a systematic review

ECMO in trauma patients (Dirk Donker)

First survivor of VA ECMO was in 1972 and was a trauma patient.

Traumatic lung injury treated by extracorporeal membrane oxygenation (ECMO) – http://www.ncbi.nlm.nih.gov/pubmed/16243331

Prevalence of Venous Thrombosis Following Venovenous Extracorporeal Membrane Oxygenation in Patients With Severe Respiratory Failure – http://journals.lww.com/ccmjournal/Citation/2015/12000/Prevalence_of_Venous_Thrombosis_Following.40.aspx

Prolonged heparin-free extracorporeal membrane oxygenation in multiple injured acute respiratory distress syndrome patients with traumatic brain injury – http://www.ncbi.nlm.nih.gov/pubmed/22673280

Venovenous extracorporeal life support improves survival in adult trauma patients with acute hypoxemic respiratory failure: a multicenter retrospective cohort study – http://www.ncbi.nlm.nih.gov/pubmed/24747460

Conclusion

• Feasible
• Limited heparinisation is relatively safe (not a big problem in the first week)
• Evidence is scarce
• Respiratory failure in trauma is different from non-trauma
• ECMO in trauma is challenging and complex, patients are complex

 

ICU MANAGEMENT OF SEVERE TRAUMA ANTÓNIO MARQUES / JOZEF KESECIOGLU

Managing combined injuries (Luciano Gattinoni)

Acute brain and lung injuries – contrasting needs. Trying to balance O2, CO2, TV, fluids etc

If lungs are very compliant, ventilation is not going to be a problem.

Alternatives strategies

• Intracheal gas insufflation
• High frequency oscillation
• VV extracorporeal CO2 removal

High Pleural pressure and PCO2 strategies

• Protective lung ventilation
• Prone (care with position of the head)
• Abdominal pressure considerations

Intra-abdominal pressure may be decreased non-invasively by continuous negative extra-abdominal pressure (NEXAP).

Effects of continuous negative extra-abdominal pressure on cardiorespiratory function during abdominal hypertension: an experimental study

Conservative management of abdominal trauma (Luke Leenen)

Non-operative management of abdominal trauma is increasingly utilised. Non operative management of liver trauma was routinely used from the 1980s

Puritanism/Free air/Abdominal gunshot still reasons to go to OR.

Abdominal trauma can result in bleeding but also CONTAMINATION

Increase in non operative management goes hand in hand with improvements in imaging

Sonography as the primary screening method in evaluating blunt abdominal trauma – ncbi.nlm.nih.gov/pubmed/15856519

Multiplicity of Solid Organ Injury: Influence on Management and Outcomes after Blunt Abdominal Trauma

Delayed splenic rupture – no evidence for bedrest. Success of non operative management is not predicted by grade of injury or size of haematoma.

Nonoperative management of blunt splenic injury: what is new?

Prospective trial of angiography and embolization for all grade III to V blunt splenic injuries: nonoperative management success rate is significantly improved.

Observation Versus Embolization in Patients with Blunt Splenic Injury After Trauma: A Propensity Score Analysis.

Adjuncts to non-operative management

• embolisations
• ERCP
• Laparoscopy
• CT guided drainage

Pitfalls are small bowel, pancreas and diaphragmatic injuries not readily seen on CT.

Emergency room management of patients with blunt major trauma: evaluation of the multislice computed tomography protocol exemplified by an urban trauma center

 

Compartment syndromes (Jacques Duranteau)

Abdominal and compartment syndrome of the extremitis requires timely diagnosis

Primary abdo compartment syndrome develops in patients with abdominal injuries.

Secondary abdo compartment syndrome develops in pts needing large volumes of transfusion/fluids for other injuries

Abdominal Compartment Syndrome: pathophysiology and definitions – http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2654860/

Postinjury abdominal compartment syndrome: from recognition to prevention

Secondary abdominal compartment syndrome after severe extremity injury: are early, aggressive fluid resuscitation strategies to blame? – http://www.ncbi.nlm.nih.gov/pubmed/18301187