Evolving Thinking in The Management of Hemorrhagic Shock

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Evolving Thinking in The Management of
Hemorrhagic Shock
TRAUMA ANESTHESIA
Jeffrey Groom, PhD, CRNA Chair and Associate
Professor of Anesthesiology Nursing College of
Nursing and Health Sciences - Florida
International University
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Bang Bang Bang
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Overview.

• Pathophysiology of shock
• Traditional management of shock
• Evolving research in shock
• Where we are headed

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Pathophysiology of Shock

• Etiology of shock
• Hemorrhagic Shock
• Impaired systemic cellular perfusion

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Pathophysiology of Shock
Impaired Perfusion
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Poiseuilles Law
Rate of flow Pressure differential
Flow X Area Viscosity
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Traditional Management of Hemorrhagic Shock
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Traditional Management of Hemorrhagic Shock

• Trendelenberg Position
• MAST or PASG (shock suit)
• IV Fluid Resuscitation

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Advanced TraumaLifeSupport
Does it improve outcome?
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Challenges to Traditional Treatment for
Hemorrhagic Shock
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MAST or PASG (Shock Suits)

• Shock Suits adopted as a standard of care
• No prospective clinical trials demonstrating
  their efficacy

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Prospective MAST Studyin 911 Patients

• Mattox KL Bickell WPepe PE, et alBaylor
  College of Medicine, Houston, TexasJournal of
  Trauma 1989 Aug29(8)1104-1111

• Adult trauma patients- scene BP lt 90mmHG
• ODD/EVEN days - NO MAST vs. MAST
• Single EMS system and Trauma Center

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Prospective MAST Studyin 911 Patients
NO-MAST GROUP MAST GROUP

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Prospective MAST Studyin 911 Patients
89 of injuries penetrating wounds
Location Frequency Thorax 41Abdome
n 32Extremity 16Head 7Neck 4
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Prospective MAST Studyin 911 Patients
PATIENT OUTCOME
No-MAST MAST 75 69
Survival
Abdominal 78 69 Abd
Vascular 85 49Thoracic
72 57Cardiac
67 30 plt0.05
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The Debate About Fluids

• Crystalloids
• Colloids
• Hypertonics
• Blood Substitutes

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Survival Fluid vs No Fluid
ISS BP Fluid No Fluid
lt 25 gt 90 99 99
25 50 gt 90 84 86
lt 90 63 62
gt 50 gt 90 26 29
lt 90 10 14
Kaweski, et al 1990
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Support for Traditional Management of Hemorrhagic
Shock
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ASSUMPTION

• Elevating BLOOD PRESSURE Improves Outcome

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Traditional Models for the Study of Shock and
Trauma
Fixed Volume Removed
TREATMENTS MAST IV FLUIDS
Whole Blood Returned
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Traditional Model DOES NOT Model Real World Trauma
Fixed Volume Model
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Trauma is NOT Generic
TRAUMA Penetrating Injury Blunt Injury Thermal
Injury Head Injury Trunk Injury Extremity Injury
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Dynamic Models for the Study of Shock and Trauma
New data suggests that elevation of blood
pressure as goal of treatment may be detrimental.
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IV Crystalloid After Aortotomy
Blood Loss Survival
NO Fluid 783 ml 8 / 8
IV Fluid 2,142 ml 0 / 8
Bickell, et al 1989
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HSD vs LR in Uncontrolled Hemorrhage
Blood Loss Survival
NO Fluid 783 ml 8 / 8
Hypertonic Saline - Dextran 1,340 ml 3 / 8
Lactated Ringers 2,142 ml 0 / 8
Bickell, et al 1989
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Effect of Blood Pressure in Uncontrolled
Hemorrhage




MAP Blood Loss Survival
40 mmHg 251 ml 89
60 mmHg 410 ml 78
80 mmHg 919 ml 22
Stern,SA, Dronen, SC, Birrer, PU Cincinnati,
Ohio 1991
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Effect of PASG inThoracic Aortic Injury




BP Blood Loss Survival
Control 23 ml/min 455 ml 100
100 mmHg 33 ml/min 965 ml 50
120 mmHg 108 ml/min 1290 ml 0
Ali J, Vanderby B, Purcell CUniversity of
Toronto 1991
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Historical Data
First recorded concerns about fluids before
hemostasis
Cannon, Fraser, Cowell Prevention of wound shock.
JAMA 191870618-621
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Aggressive Fluid Resuscitation and Elevation of
BP Results in

• Accelerated hemorrhage
• Disruption of clot formation
• Dilution of clotting factors
• Decreased blood viscosity
• Greater overall blood loss and lowered
  survival rates
• Other Abd Cmpt Synd, ARDS

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Poiseuilles Law
Rate of flow Pressure differential
Flow X Area Viscosity
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Dynamic Models for the Study of Shock and Trauma
Elevation of blood pressure BEFORE hemostasis may
be detrimental.
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Immediate vs. Delayed Fluid Resuscitation for
Hypotensive Patients with Penetrating Torso
Injuries

• Bickell WH, Wall MJ, Pepe PE, et alBaylor
  College of Medicine, Houston, TexasNew England
  Journal of Medicine 1994 331(17)1105-1109

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Immediate vs. Delayed Fluid Resuscitation for
Hypotensive Patients with Penetrating Torso
Injuries
The Issue is Timing
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PATIENT SELECTION CRITERIA
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STUDY METHODOLOGY
Alternate day protocol Standard IV Fluids
vs Hep-Loc
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Immediate vs Delayed Resuscitation
PatientCharacteristic Immediate (N309) Delayed(N289)
Age 31 11 yrs 31 10 yrs
Males 88 91
Systolic BP 58 35 mmHg 59 34 mmHg
Injury Severity 26 14 26 14
Trauma Score 5.4 2.1 5.6 2.1
Mean SD
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Immediate vs Delayed Resuscitation
Mechanismof Injury Immediate (N309) Delayed(N289)
Gunshot wound 65 67
Stabwound 29 30
Shotgun-blast wound 6 3
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Immediate vs Delayed Resuscitation
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Immediate vs Delayed Resuscitation
OR FluidVolumes (ml) Immediate (N268) Delayed(N260)
Ringers 6772 4688 6529 4863
Packed Cells 1942 1713
FFP 357 307
Autologous 95 111
Hetastarch 499 542
Intra Op EBL 3127 4937 2555 3546
p lt 0.05
Mean SD
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Immediate vs Delayed Resuscitation
OverallOutcome Immediate (N309) Delayed(N289)
ICU Stay 8 16 7 11
Hospital Stay 14 24 11 19
Survival 193/309 59 203/289 72
p lt 0.05
Mean SD
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What do the results mean?
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Comparison of Standard and AlternativeResuscitati
on inUncontrolled Hemorrhagic Shock
Recent Experiments and Clinical Trials

• Uncontrolled Hemorrhage Models
• Timing of hemostasis and resuscitation
• Fluid resuscitation
• Non-surgical hemostatsis
• Role of biochemical mediators

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Prolonged Severe Hemorrhagic Shock and
Resuscitation in RatsDoes Not Cause Subtle Brain
Damage
Carrillo P, Takasu A, Safar P, et alSafar Center
for Resuscitation, Pittsburgh, PennsylvaniaJourna
l of Trauma Aug47(2)239-248
3 Groups Control MAP 40mmHg MAP 30 mmHg
Survival 12/12 10/17
10/14
No significant neurological functional or
histological differences
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How do we make this new info work
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Controlled vs UncontrolledHemorrhage
Controlled
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(No Transcript)
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Recent Interventions

• Stop hemorrhage
• Blood and Fluid Interventions
• Pharmacologic Interventions

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Stop Hemorrhage
TOURNIQUETS
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Stop Hemorrhage
TOURNIQUETS
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Stop Hemorrhage
CLAMP COMPRESSION
Combat Ready Clamp (CRoC)
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Stop Hemorrhage
CLAMP COMPRESSION
Jett Junctional Emergency Treatment Tool
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Stop Hemorrhage
Abdominal Aortic Tourniquet
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Stop Hemorrhage
TRAUMA CLAMP
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Stop Hemorrhage
HEMOSTATICS
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Blood and Fluid Interventions

• Permissive hypotension (in pts w/o CNS injury)
• Emergency PRBCs w/ O neg FFP w/ AB
• Massive Transfusion Protocol
• Military - 111 resuscitation6 U PRBCs 6 U
  FFP 1 U Platelets(10 U Cryopreciptate) (1
  apheresis unit 6 units random donor platelets
  1 6-pack)
• Based on better outcomes with fresh whole blood
  but many logistical barriers to whole blood
• Blood Substitutes
• Hemoglobin-based oxygen carrying solutions
  (HBOCs)
• PolyHeme
  Hemopure Chemically-modified hemoglobin
  Derived from bovine blood Refriged
  / 1 Year Shelf Life
  Room Temp / 3 years

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Pharmacologic Interventions

• Vasopressors
• Vasopressin (Pitressin)
• Pro-clotting Agents
• Amino acid antifibrinolytics Tranexamic acid (8x
  aminocaproic acid Amicar)(1 gram of tranexamic
  acid in 100 ml of 0.9 NS over 10 minutes, direct
  IV)
• - Recombinant Factor VIIa Novoseven,
  rFVIIa
• (Limited to MT cases at present) (Infuse rFVIIa
  at dose of 90-120 mcg/kg IV push)

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Whats in the future ?
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Bang Bang Bang
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Management in the future
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Role of Induced Hypothermia
Improved outcomes post-medical arrest
Application to trauma arrest ?
Biocellular
Hypothermia
Bleeding Control
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Role of Biocelluar Interventions
Biocellular
Histone deacetylase inhibitors (HDACI) Valproic
acid (Depakene) Suberoyanilide hydroxamic acid
(Vorinostat)Modulate the inflammatory response
after hemorrhage
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Role of Biocelluar Interventions
Biocellular

• Nanoparticle Synthetic Platelets
• stick to natural platelets and result in quicker
  and more efficient clotting
• better than factor VIIa in stopping internal
  bleeding and increased survival

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Role of Blood Substitutes
Blood Substitutes
Oxygen Bridge
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Hemoglobin glutamer-250 HBOC-201 (Hemopure)

Restore Effective Survival in Shock (RESUS)
Phase 2 Clinical Trial
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Role of Bleeding Control
Bleeding Control
Doppler and Ultrasound Technologies
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Role of Bleeding Control
Noninvasive Hemorrhage Detection and Treatment

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Role of Bleeding Control
Noninvasive Hemorrhage Detection and Treatment
GE Healthcare Vscan
Vscan Video Link
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Role of Bleeding Control
Deep Bleeder Acoustic Coagulation
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What doesit all mean?
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Advanced TraumaLifeSupport
What makes the most improvement in outcome?
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ANY QUESTIONS ?