Applying ROTEM to the Management of Bleeding in Trauma
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1 Applying ROTEM to the Management of Bleeding in Trauma Sandro Rizoli, MD PhD FRCSC FACS Professor Surgery & Critical Care Medicine Trauma Program Director Chair Trauma Care
2 Disclosure NONE
3 ROTEM Growing evidence usefulness Cardiac surgery, liver transplant, etc Incipient in trauma Why care about a lab test?
4 Introduction 1. Trauma is common 2. 1 st cause mortality (young) 3. Bleed a lot (1 st hospital death; 90% cryo; 50% FFP) 4% CNS + Exsanguination 1% Other 4% Organ Failure 40% Head 51% Exsanguination &C Coagulopathy Sauaia et al J Trauma 1995;38:185
5 Two types of bleeding Mechanical - surgery Coagulopathic - blood
6 Coagulopathy 21 st Century Until 2003 (Brohi) After 2003 Bleeding Endogenous Within minutes Coagulopathy 25% patients Shock Tissue damage Dilution Hypothermia Acidosis Etc; etc 3x mortality
7 Mechanism 1 Anticoagulation Trauma Shock Endothelial damage TM + Thrombin PC APC FV (-) Thrombin generation Clot formation anticoagulated
8 Mechanism 2 Hyper fibrinolysis APC (-) PAI-1 + Fibrinolysis Clot lysis fibrinolysis + (-) fibrinogen tpa
9 Mechanism 3 Hypo fibrinogemia Fibrinogen = CRITICAL 1 ary & 2 ary hemostasis 1 st to drop (140% - plat 230%) Consumption Dilution Small reserves (10g) Hyperfibrinolysis = 86% mortal.
10 Mechanism 4 Other Hypothermia & acidosis i = CRITICAL Decrease thrombin generation Fibrinogen synthesis Fibrinogen degradation Clot factors (enzymes) Mechanism 5 DIC = no evidence
11 Pathophysiology h Unique & early Shock + tissue destruction Complex (multiple defects) a. Anticoagulation = APC b. Hyper fibrinolysis = tpa c. Imbalances a d. Low fibrinogen e. Hypothermia, acidosis
12 10 Management How did the 21 st century change the resuscitation of bleeding trauma patients
13 Management 1. Lab-guided time to results POC limitations catch up no evidence Chandler (Transfusion 2010) Rapid bleed panel <20min (10-15min 15min verbal)
14 Management 2. Formula one size fits all DCR or 1:1:1 everyone is (or will be) coagulopathic everyone needs plasma (± platelet) start plasma as early as possible no lab required limit use crystalloids
15 Management 2. Formula one size fits all DCR or 1:1:1 TRFL study CMAJ 2013;185(12) inappropriate transfusion wastage increase complications (ARDS, sepsis)?? mortality Nascimento Callum
16 Ideal Resuscitation Dr McCoy y( (Star Trek) tricorder Ideal: instant results M lti l l thi Multiple coagulopathies Individualized care
17 ROTEM Advantages over conventional tests: 1. Differentiate mechanical vs. coagulopathic 2. Guide transfusion 3. Hypo coagulation: A5 or MCF A5<35mm 77% massive transfusion 4. Hyper fibrinolysis: ML or LY30 Death sentence % literature 75% Toronto
18 Callum ROTEM for Surgeons (Idiots) Claghorn A5<35 give platelets LY30 <95% give tranexamic acid EXTEM FIBTEM CT>100 give 4 FFP MCF<7 give 10 cryo
19 Real Life arrival A. Blood Results B. TEG Results Parameter Result Hemoglobin (g/l) 50 Platelets (10 9 /L) 55 INR 2.4 PTT (seconds) > 150 D-dimers (ng/ml) 7750
20 30 4h 28h 24h
21 Real Life 60yo M pedestrian hit by car Pre-hospital: GCS 5, intubated t at tthe scene Hypotensive, given 4L crystalloid Right chest tube ~ 500 ml Trauma Room: BP 110/50; HR 83 CT chest = multiple rib fractures CT abd = complex pelvic fracture
22 Lab & Clinical Progress 0h 4h later Hg Plat INR PTT 29 Lactate st hour 3U RBC + 4U FFP 4h later = crash Hypotensive Taken to angio Embolization pelvis 7.14/65/311/21 100% Fibrinogen = 1 (normal 2g/L)
23 EXTEM CT 57 (38-79) α-angle g 63 (63-88) A5 31 (>35) MCF 53 (50-72) ML 9% (<15%) FIBTEM A56 A10 6 (7-23) MCF 8 (9-25)
24 Lethal triad coagulopathy = INR 1.47 acidotic = lactate 3.5/pH 7.14 bled/bleeding = Hg 78 ROTEM low = A5 & fibtem MCF 4U FFP = INR not corrected (difficult correct INR 1.47) Tranexamic acid NOT given Coagulopathic = crash later ( no active bleeding on CT)? more aggressive correct fibrinogen, platelet? Best treatment customized examination + lab (INR, lactate) + ROTEM
25 Management Guess the outcome!
26 EXTEM FIBTEM CT 86 (38 79) CFT 133 (34 159) α angle 70 (63 88) A5 29 (>35) A10 5 (43 66) MCF 28 (50 72) LI30 12 (94 100) ML 100% (<15%) A5 7 A10 2 (7 23) A20 1 (8 24) MCF 8 (9 25)
27 Thank you
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