Tag Archives: haemorrhage

Fibrinogen concentrate

A case report of massive obstetric haemorrhage due to placental abruption describes the successful management of haemorrhage associated with a low fibrinogen level with blood products that included fibrinogen concentrate.

Fibrinogen concentrate can be available more quickly than other clotting products as it is rapidly solubilised from an ampoule in 50 ml water and given as a bolus. To raise the plasma fibrinogen concentration by 1 g/l in a 70-kg person, 1000 ml fresh frozen plasma (6 standard UK units), or 260 ml cryoprecipitate (10 standard UK units) will be required. Administration of adequate doses of fresh frozen plasma or cryoprecipitate to treat hypofibrinogenaemia during obstetric haemorrhage will therefore take a substantial amount of time, even with an efficient blood bank and portering system.
Fibrinogen concentrate use during major obstetric haemorrhage
Anaesthesia 2010;65(12):1229–1230
A previous retrospective study showed its use in a series of surgical and obstetric haemorrhage cases may have been associated with a subsequent decreased need for other blood products.
Fibrinogen concentrate substitution therapy in patients with massive haemorrhage and low plasma fibrinogen concentrations
Br. J. Anaesth. (2008) 101 (6): 769-773 (Full text)

Pelvic splint improved shock

Splinted any pelvises lately? Karim Brohi’s excellent trauma.org article outlines the strengths and weaknesses of the different devices on the market. One such is the T-POD, which has now been described in a small series in which its application to patients with unstable pelvic injury was associated with improved haemodynamics and decreased symphyseal diastasis.

Here’s a video demonstrating application of the device.

Effect of a new pelvic stabilizer (T-POD1) on reduction of pelvic volume and haemodynamic stability in unstable pelvic fractures
Injury Volume 41, Issue 12, December 2010, Pages 1239-1243 (Full text)

Massive haemorrhage guideline

The Association of Anaesthetists of Great Britain and Ireland has published guidelines on the management of massive haemorrhage. Their summary:

  1. Hospitals must have a major haemorrhage protocol in place and this should include clinical, laboratory and logistic responses.
  2. Immediate control of obvious bleeding is of paramount importance (pressure, tourniquet, haemostatic dressings).
  3. The major haemorrhage protocol must be mobilised immediately when a massive haemorrhage situation is declared.
  4. A fibrinogen < 1 g.l)1 or a prothrombin time (PT) and activated partial thromboplastin time (aPTT) of > 1.5 times normal represents established haemostatic failure and is predictive of microvascular bleeding. Early infusion of fresh frozen plasma (FFP; 15 ml.kg)1) should be used to prevent this occurring if a senior clinician anticipates a massive haemorrhage.
  5. Established coagulopathy will require more than 15 ml.kg)1 of FFP to correct. The most effective way to achieve fibrinogen replacement rapidly is by giving fibrinogen concentrate or cryoprecipitate if fibrinogen is unavailable.
  6. 1:1:1 red cell:FFP:platelet regimens, as used by the military, are reserved for the most severely traumatised patients.
  7. A minimum target platelet count of 75 · 109.l)1 is appropriate in this clinical situation.
  8. Group-specific blood can be issued without performing an antibody screen because patients will have minimal circulating antibodies. O negative blood should only be used if blood is needed immediately.
  9. In hospitals where the need to treat massive haemorrhage is frequent, the use of locally developed shock packs may be helpful.
  10. Standard venous thromboprophylaxis should be commenced as soon as possible after haemostasis has been secured as patients develop a prothrombotic state following massive haemorrhage.

Blood transfusion and the anaesthetist: management of massive haemorrhage – full document

rFVIIa did not reduce trauma mortality

An industry sponsored placebo-controlled multicentre randomised controlled trial has shown no mortality reduction from recombinant activated Factor VII (rFVIIa) in patients with trauma.
rFVIIa acts physiologically by enhancing clot formation in the presence of tissue factor expressed on injured or ischemic vascular subendothelium. It also acts pharmacologically, binding directly to activated platelets, increasing thrombin burst, and promoting the formation of a stable hemostatic plug.
Blunt and/or penetrating trauma patients aged 18 years to 70 years were eligible if they had continuing torso and/or proximal lower extremity bleeding after receiving 4 units of RBCs despite standard hemostatic interventions. There was no 30 day mortality reduction, although fewer blood products were transfused from dosing to 24 hours in the rFVIIa group.
No significant difference was seen in the safety profile of rFVIIa compared with placebo.
The CONTROL trial was terminated early (573 of 1502 patients) after an interim analysis suggested a high likelihood of futility in demonstrating the primary endpoint in the blunt trauma population.
Results of the CONTROL Trial: Efficacy and Safety of Recombinant Activated Factor VII in the Management of Refractory Traumatic Hemorrhage
Journal of Trauma-Injury Infection & Critical Care September 2010 69(3):489-500

Tactical Combat Casualty Care

The brave men and women of the military not only risk their lives for us – they also provide a wealth of trauma experience and publish interesting stuff.
This month’s Journal of Trauma contains a military trauma supplement. One of the articles describes the latest guidelines on Tactical Combat Casualty Care. These include:

  • tourniquet use
  • Quikclot Combat Gauze as the haemostatic agent which has replaced Quikclot powder and HemCon. This preference is based on field experience that powder and granular agents do not work well in wounds in which the bleeding vessel is at the bottom of a narrow wound tract or in windy environments. WoundStat was a backup agent but this has been removed because of concerns over possible embolic and thrombotic complications.
  • longer catheters for decompression of tension pneumothorax (Harcke et al. found a mean chest wall thickness of 5.36 cm in 100 autopsy computed tomography studies of military fatalities. Several of the cases in their autopsy series were noted to have had unsuccessful attempts at needle thoracostomy because the needle/catheter units used for the procedure were too short to reach the pleural space*.)
  • close open chest wounds immediately with an occlusive material, such as Vaseline gauze, plastic wrap, foil, or defibrillator pads
  • a rigid eye shield and antibiotics for penetrating eye injury

Tactical Combat Casualty Care: Update 2009
The Journal of TRAUMA 2010;69(1):S10-13 (no abstract available)
Full text of guidelines in PDF at itstactical.com
*Harcke HT, Pearse LA, Levy AD, Getz JM, Robinson SR. Chest wall thickness in military personnel: implications for needle thoracentesis in tension pneumothorax. Mil Med. 2007;172:1260 –1263

Military pre-hospital thoracotomy

Military doctors in Afghanistan reviewed their experience of thoracotomy done within 24 hours of admission to their hospital. The ballistic nature of thoracic penetrating trauma (mainly Afghan civilians without body armour) differs from the typical knife-wound related injury seen in survivors of thoracotomy reported in the pre-hospital literature.
Six of the patients presented in cardiac arrest – four PEA and two asystole. One of the PEA patients survived; this patient had sustained a thoracoabdominal GSW and had arrested 8 minutes from hospital. Following emergency thoracotomy, aortic control, and concomitant massive transfusion, return of spontaneous circulation (ROSC) was achieved and damage control surgery undertaken in both chest and abdomen.
The two patients in asystole had sustained substantial pulmonary and hilar injuries, and ROSC was never achieved. The patients in PEA all had arrested as a consequence of hypovolaemia from solid intra-abdominal visceral haemorrhage. All patients in PEA had ROSC achieved, albeit temporarily.
Following thoracotomy, patients required surgical manoeuvres such as pulmonary hilar clamping, packing and temporary aortic occlusion; hypovolaemia was the leading underlying cause of the cardiac arrest. These factors lead the authors to conclude that although isolated cardiac wounds do feature in war, they are unusual and the injury pattern of casualties in conflict zones are often complex and multifactorial.
Is pre-hospital thoracotomy necessary in the military environment?
Injury. 2010 Jul;41(7):1008-12

Early TIPS is top

Transjugular intrahepatic portosystemic shunt (TIPS) is often used as a rescue therapy in cirrhotic patients with variceal haemorrhage after vasoactive drug therapy and endoscopic ligation have failed. A randomised study compared this standard management with earlier TIPS within 72 hours after randomisation (and randomisation occurred within 24 hours of admission). The early use of TIPS was associated with significant reductions in treatment failure and in mortality.
Not sure what TIPS is? This video I found on YouTube explains it nicely..
[youtube]http://www.youtube.com/watch?v=pGA6KUgq7AI&feature=related[/youtube]
Early Use of TIPS in Patients with Cirrhosis and Variceal Bleeding
NEJM 2010;362:2370-2379

Misoprostol for PPH

Misoprostol is a prostaglandin analogue with uterotonic activity. It was compared with placebo in its sublingual form in a randomised trial in 1422 women with postpartum haemorrhage and uterine atony. It was given with other uterotonic agents (mostly oxytocin 10IU im or slow iv). The primary outcome was blood loss of 500 mL or more within 60 min after randomisation, and this was similar in both groups.
Misoprostol as an adjunct to standard uterotonics for treatment of post-partum haemorrhage: a multicentre, double-blind randomised trial
Lancet. 2010 May 22;375(9728):1808-13

Tranexamic acid saves lives in trauma

A convincing, practice-changing trial is a rare thing in major trauma, but here comes a biggie:
The CRASH-2 trial recruited over 20 000 patients from 40 countries (sadly excluding the US because the trial investigators couldn’t afford the insurance – a sign that no large drug company was funding this trial of an inexpensive therapy).
The antifibrinolytic drug tranexamic acid was compared with placebo in adult trauma patients with, or thought to be at risk of, significant haemorrhage. Clinicians were blinded to the intervention and the primary outcome was death in hospital within 4 weeks of injury. Secondary outcomes were vascular occlusive events (myocardial infarction, stroke, pulmonary embolism, and deep vein thrombosis), surgical intervention (neurosurgery, thoracic, abdominal, and pelvic surgery), receipt of blood transfusion, and units of blood products transfused. Treatment groups were balanced with respect to all baseline patient characteristics.

All-cause mortality was significantly reduced with tranexamic acid and the risk of death due to bleeding was significantly reduced. Vascular occlusive events (fatal or non-fatal) did not differ significantly between the groups (and were fewer in the tranexamic acid group compared with the placebo group).
All cause mortality in the tranexamic acid group was (1463/10 060) = 14·5% and in the placebo group was (1613/10 067) = 16·0%. So absolute risk reduction is 1.5% and Number Needed to Treat = 67.
The same trials group is investigating the effect of tranexamic acid in post-partum haemorrhage, in a study known as the WOMAN Trial
Take Home Message: the early administration of tranexamic acid to trauma patients with, or at risk of, significant bleeding reduces the risk of death from haemorrhage with no apparent increase in fatal or non- fatal vascular occlusive events. All-cause mortality was significantly reduced with tranexamic acid.
Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo-controlled trial
The Lancet, Early Online Publication, 15 June 2010

European Trauma Bleeding Guidelines updated

 


Update 2013: since this post was written in 2010, new guidelines have been written entitled: “Management of bleeding and coagulopathy following major trauma: an updated European guideline” which are available here

 
The 2007 guidelines on management of bleeding in trauma have been updated in the light of new evidence and modern practice. The guideline group summarises their recommendations as:

  1. We recommend that the time elapsed between injury and operation be minimised for patients in need of urgent surgical bleeding control. (Grade 1A).
  2. We recommend adjunct tourniquet use to stop life-threatening bleeding from open extremity injuries in the pre-surgical setting. (Grade 1C).
  3. We recommend that the physician clinically assess the extent of traumatic haemorrhage using a combination of mechanism of injury, patient physiology, anatomical injury pattern and the patient’s response to initial resuscitation. (Grade 1C).
  4. We recommend initial normoventilation of trauma patients if there are no signs of imminent cerebral herniation. (Grade 1C).
  5. We recommend that patients presenting with haemorrhagic shock and an identified source of bleeding undergo an immediate bleeding control procedure unless initial resuscitation measures are successful. (Grade 1B).
  6. We recommend that patients presenting with haemorrhagic shock and an unidentified source of bleeding undergo immediate further investigation. (Grade 1B).
  7. We recommend early imaging (FAST or CT) for the detection of free fluid in patients with suspected torso trauma. (Grade 1B).
  8. We recommend that patients with significant free intraabdominal fluid and haemodynamic instability undergo urgent intervention. (Grade 1A).
  9. We recommend further assessment using computed tomography for haemodynamically stable patients who are either suspected of having torso bleeding or have a high risk mechanism of injury. (Grade 1B).
  10. We do not recommend the use of single haematocrit measurements as an isolated laboratory marker for bleeding. (Grade 1B).
  11. We recommend both serum lactate and base deficit measurements as sensitive tests to estimate and monitor the extent of bleeding and shock. (Grade 1B).
  12. We recommend that routine practice to detect post-traumatic coagulopathy include the measurement of international normalised ratio (INR), activated partial thromboplastin time (APTT), fibrinogen and platelets. INR and APTT alone should not be used to guide haemostatic therapy. (Grade 1C) We suggest that thrombelastometry also be performed to assist in characterising the coagulopathy and in guiding haemostatic therapy. (Grade 2C).
  13. We recommend that patients with pelvic ring disruption in haemorrhagic shock undergo immediate pelvic ring closure and stabilisation. (Grade 1B).
  14. We recommend that patients with ongoing haemodynamic instability despite adequate pelvic ring stabilisation receive early preperitoneal packing, angiographic embolisation and/or surgical bleeding control. (Grade 1B).
  15. We recommend that early bleeding control of the abdomen be achieved using packing, direct surgical bleeding control and the use of local haemostatic procedures. In the exsanguinating patient, aortic cross-clamping may be employed as an adjunct. (Grade 1C).
  16. We recommend that damage control surgery be employed in the severely injured patient presenting with deep hemorrhagic shock, signs of ongoing bleeding and coagulopathy. Additional factors that should trigger a damage control approach are hypothermia, acidosis, inaccessible major anatomic injury, a need for time-consuming procedures or concomitant major injury outside the abdomen. (Grade 1C).
  17. We recommend the use of topical haemostatic agents in combination with other surgical measures or with packing for venous or moderate arterial bleeding associated with parenchymal injuries. (Grade 1B).
  18. We recommend a target systolic blood pressure of 80-100 mmHg until major bleeding has been stopped in the initial phase following trauma without brain injury. (Grade 1C).
  19. We recommend that crystalloids be applied initially to treat the bleeding trauma patient. (Grade 1B) We suggest that hypertonic solutions also be considered during initial treatment. (Grade 2B) We suggest that the addition of colloids be considered within the prescribed limits for each solution in haemodynamically unstable patients. (Grade 2C).
  20. We recommend early application of measures to reduce heat loss and warm the hypothermic patient in order to achieve and maintain normothermia. (Grade 1C).
  21. We recommend a target haemoglobin (Hb) of 7-9 g/dl. (Grade 1C).
  22. We recommend that monitoring and measures to support coagulation be initiated as early as possible. (Grade 1C).
  23. We recommend that ionised calcium levels be monitored during massive transfusion. (Grade 1C) We suggest that calcium chloride be administered during massive transfusion if ionised calcium levels are low or electrocardiographic changes suggest hypocalcaemia. (Grade 2C).
  24. We recommend early treatment with thawed fresh frozen plasma in patients with massive bleeding. (Grade 1B) The initial recommended dose is 10-15 ml/kg. Further doses will depend on coagulation monitoring and the amount of other blood products administered. (Grade 1C).
  25. We recommend that platelets be administered to maintain a platelet count above 50 × 109/l. (Grade 1C) We suggest maintenance of a platelet count above 100 × 109/l in patients with multiple trauma who are severely bleeding or have traumatic brain injury. (Grade 2C) We suggest an initial dose of 4-8 platelet concentrates or one aphaeresis pack. (Grade 2C).
  26. We recommend treatment with fibrinogen concentrate or cryoprecipitate if significant bleeding is accompanied by thrombelastometric signs of a functional fibrinogen deficit or a plasma fibrinogen level of less than 1.5-2.0 g/l. (Grade 1C) We suggest an initial fibrinogen concentrate dose of 3- 4 g or 50 mg/kg of cryoprecipitate, which is approximately equivalent to 15-20 units in a 70 kg adult. Repeat doses may be guided by thrombelastometric monitoring and laboratory assessment of fibrinogen levels. (Grade 2C).
  27. We suggest that antifibrinolytic agents be considered in the bleeding trauma patient. (Grade 2C) We recommend monitoring of fibrinolysis in all patients and administration of antifibrinolytic agents in patients with established hyperfibrinolysis. (Grade 1B) Suggested dosages are tranexamic acid 10-15 mg/kg followed by an infusion of 1-5 mg/kg per hour or ε-aminocaproic acid 100-150 mg/kg followed by 15 mg/kg/h. Antifibrinolytic therapy should be guided by thrombelastometric monitoring if possible and stopped once bleeding has been adequately controlled. (Grade 2C).
  28. We suggest that the use of recombinant recombinant activated coagulation factor VII (rFVIIa) be considered if major bleeding in blunt trauma persists despite standard attempts to control bleeding and best-practice use of blood components. (Grade 2C).
  29. We recommend the use of prothrombin complex concentrate for the emergency reversal of vitamin K-dependent oral anticoagulants. (Grade 1B).
  30. We do not suggest that desmopressin (DDAVP) be used routinely in the bleeding trauma patient. (Grade 2C) We suggest that desmopressin be considered in refractory microvascular bleeding if the patient has been treated with platelet-inhibiting drugs such as aspirin. (Grade 2C).
  31. We do not recommend the use of antithrombin concentrates in the treatment of the bleeding trauma patient. (Grade 1C).

Management of bleeding following major trauma: an updated European guideline.
Crit Care. 2010 Apr 6;14(2):R52 (Pub Med abstract)
Full Text Link