Choc hmorragique - polytraumatisme

J. Duranteau
Hpital de Bictre - Universit Paris-Sud XI
Gestion du choc hmorragique en traumatologie

Mortalit prcoce est principalement lie une

hmorragie non controle (3050% des morts prcoces)
50% interviennent sur les lieux de laccident
30% interviennent dans les 24res heures
20% interviennent tardivement

La mortalit tardive est due aux dysfonctions dorganes;

lincapacit est due essentiellement au traumatismes
craniens associs

le traumatisme cranien est un des traumatisme le plus

souvent associ au polytraumatiss patients
Gestion du choc hmorragique en traumatologie

Centres spcialiss

Pas de perte de temps

Stratgie claire pour lquipe

mdico-chirurgicale

Prise de dcisions

Contrle rapide de lhmorragie

A multicenter, retrospective cohort analysis of all patients with trauma transported directly from
the scene to a Level I or a Level II hospital between January 2003 and December 2006.

Level I
1. Regional resource hospital that is central to trauma care system.
2. Provides total care for every aspect of injury, from prevention through rehabilitation.
3. Maintains resources and personnel (trauma, neuro and orthopedic surgeons 24h/7J)
for patient care, education and research (usually in university-based teaching hospital).
4. Provides leadership in education, research and system planning to all hospitals caring
for injured patients in the region.

Level II
1. Provides comprehensive trauma care, regardless of severity of the injury.
2. Works in collaboration with a Level I center.
3. Provides 24-hour availability of all essential specialties, personnel, and equipment.

Cudnik MT, J Trauma. 2009;66:13211326

 Outcomes of Stratified Analysis of Those With
Severe Injuries (ISS >15), Severe Head Injuries (GCS
<9), or Blunt Trauma Taken to a Level I Center

Odds of Mortality by Stratified Analysis

of Those With Specific Injuries by ICD-9
Codes Taken to a Level I Center

Cudnik MT, J Trauma. 2009;

66:13211326
Gestion du choc hmorragique en traumatologie

Identifier le choc hmorragique

Identifier lorigine du saignement

Maintien de la perfusion tissulaire

Prvention de la coagulopathie

Contle rapide du saignement

Gestion du choc hmorragique en traumatologie

Identifier le choc hmorragique

Identifier lorigine du saignement

Maintien de la perfusion tissulaire

Prvention de la coagulopathie

Contle rapide du saignement

American College of Surgeons Advanced Trauma Life Support (ATLS) classification
of haemorrhage severity
Gestion du choc hmorragique en traumatologie

Identifier le choc hmorragique

Identifier lorigine du saignement

Maintien de la perfusion tissulaire

Prvention de la coagulopathie

Contle rapide du saignement

Radiographies standard
Focused Assessment
of the Sonographic examination
of Trauma patients

Pricarde

Prihpatique
Prisplenique

Pelvis Sensibilit = 70-90 %, spcificit = 90-100 %

Instablilit hmodynamique : sensibilit = 100 %
Wherrett LJ, J Trauma 1996;41:815-20
Echographie
Spcificit = 100 % pour le diagnostic de pneumothorax

Lichtenstein D, Intensive Care Med. 2000 Oct;26(10):1434-40.

Corrlation (r = 0.68; p < 0.001)
volume / distance poumon-paroi (PLD)

PLD base > 5 cm = volume > 500mL

Se = 83 %
Sp = 90 %
VPP = 91 %, VPN = 82 %

Roch A, Chest. 2005 Jan;127(1):224-32

Transcranial Doppler

Middle Cerebral
Artery (MCA)

Transtemporal window
Above the
zygomatic arch

2-MHz pulsed Doppler

probe
Transcranial Doppler

Middle cerebral
artery Systolic Velocity
Diastolic Velocity

Pulsatility index

50 mm

Peak systolic velocity (Vs)

End-diastolic velocity (Vd)
Time-averaged mean velocity (Vm)
Pulsatility index: PI = (Vs Vd)/Vm (0.6 to 1.1)
Transcranial Doppler

Middle cerebral
artery Systolic Velocity
Diastolic Velocity

Pulsatility index

50 mm

Vm < 30 cm/s
Vd < 20 cm/s
PI > 1.2

Intracranial hypertension
computed tomography scanner

For haemodynamically stable patients

Assessment using computed tomography

For haemodynamically unstable patients

The clinician must evaluate the
implications and potential risks and
benefits of the procedure

The future = CT scanners integrated in

resuscitation units
WurmbTE et al., J Trauma 2009
Gestion du choc hmorragique en traumatologie

Identifier le choc hmorragique

Identifier lorigine du saignement

Maintien de la perfusion tissulaire

Prvention de la coagulopathie

Contle rapide du saignement

Cathterisme artriel et veineux fmoral
Transfuseurs massifs
Trauma Remplissage vasculaire

Remplissage vasculaire
Restauration de la volmie pour assurer une perfusion tissulaire
Suffisante et prvenir les dysfonctions dorganes

Mais un remplissage vasculaire important peut :

Diluer les facteurs de coagulation et les plaquettes
Provoquer une augmentation excessive de la PA
Induire un risque de syndrme de compartiment
(abdominal membres)
 Choc hmorragique
PAS < 90 mmHg, PAM < 60 mmHg

Remplissage vasculaire

1000 - 1500 mL

PAS < 80; PAM < 60 mmHg

PA
Vasopresseur - Norepinephrine
80 PAS 90 mmHg Dbute 0.5 mg/h ou 0.1 g/kg/min
60 PAM 65 mmHg

PP
VES

Transfusion produits
drivs du sang
Hb 7-9 g.dL-1
TP > 40%
Plaquettes 50.109 L-1

Hmostase chirugicale
ou artrioembolisation
 Choc hmorragique
PAS < 90 mmHg, PAM < 60 mmHg

Traumatisme cranien
CGS 8 Remplissage vasculaire

1000 - 1500 mL

PAS < 120; PAM < 90 mmHg

PA
Vasopresseur - Norepinephrine
PAS 120 mmHg Dbute 0.5 mg/h ou 0.1 g/kg/min
PAM 90 mmHg

PP
VES

Transfusion produits
drivs du sang
Hb 10 g.dL-1 Vlocit diastolique < 25 cm/s
TP > 50% IP = (V Syst- V Diast)/ V moyenne > 1,2
Plaquettes 80-100.109 L-1
Hypertension intracranienne
Hmostase chirugicale
ou artrioembolisation
FIRST 14 centers
December 2004-Mars 2007

350 _
Catecholamines
300 _
320
250 _ 89 %
260 73 %
58 %
200 _ 236
211
150 _ 184 189

100 _

50 _

0_

1-3 RBC/24h 4-7 RBC/24h >7 RBC/24h

Norepinephrine increases cardiac preload and reduces preload
dependency assessed by passive leg raising in septic shock
patients
25 septic shock patients receiving
norepinephrine
with a positive passive leg raising test

Monnet X. et al. Crit Care Med 2011; 39:689

694
Nouira S. et al. Crit Care Med 2005:2339-
2343
 NE 50
MAP 87 8

NE 0 NE 5 NE 0 NE 50
MAP 57 14 MAP 64 7 MAP 80 MAP 81 14
8
100 -
Number of survivors

Saline 4 mL/100 g
80 - Blood loss 0.3 mL/100g

Saline 3-5 mL/100 g

60 - Blood loss 0.5 0.7 mL/100g

40 -

20 -

0-

Saline 5 mL/100 g Saline 17 mL/100 g Poloujadoff, MP et al.

Blood loss 0.4 mL/100g Blood loss 1.88 mL/100g Anesthesiology
2007; 107:5916
 Data were derived from the ongoing multicenter prospective
cohort study designed to evaluate the outcome of blunt
injured adults in hemorrhagic shock. (November 2003 to March 2007)
1,036 patients
The overall mortality rate was 12.3%

Sperry JL et al. J Trauma.

Phenylephrine, norepinephrine, 2008;64:914
dopamine, and vasopressin

Aggressive Crystalloid Resuscitation

> 16 L at 12 hours and > 20 L at 24 hours
 This study is a secondary analysis of a prospective cohort study
Not design to answer the specific hypothesis tested.

No EV (N = 802) EV (N = 119)
Injury Severity Score 30 13 34 14
Blood transfusion (>6 units), % 43 64
Early laparotomy (48h), % 41 51
Early Thoracotomy (48h), % 4 19

Phenyleprine: pure alpha-adrenergic agent

Epinephrine were categorized in the No EV group
Combinations of vasopressor therapy were used
Trauma Remplissage vasculaire

Remplissage vasculaire
Restauration de la volmie pour assurer une perfusion tissulaire
Suffisante et prvenir les dysfonctions dorganes

Mais un remplissage vasculaire important peut :

Diluer les facteurs de coagulation et les plaquettes
Provoquer une augmentation excessive de la PA
Induire un risque de syndrme de compartiment
(abdominal membres)
Prevention of coagulopathy

Cercle vicieux

Saignement

Coagulopathie Ranimation

Hmodilution
hypothermie
Early coagulopathy in multiple Injury: An analysis from the German
Trauma Registry on 8724 patients

Retrospective analysis using the German Trauma Registry database

Coagulopathy upon ER admission (prothrombin time test <70% and/or platelets <100,000 microl -1)

Maegele M et al. Injury.

2007;38(3):298-304

Coagulopathy upon ER admission in 34.2% of all patients.

Coagulopathy was observed in >40% of patients with >2000 ml, in >50% with >3000 ml, and in >70% with >4000 ml
 No evidence that resuscitation with colloids reduces the risk of
death, compared to resuscitation with crystalloids, in patients with
trauma, sepsis, burns or following surgery

Perel P, Roberts I. Cochrane Database Syst Rev. 2007

 Crystalloids colloids ?

Crystalloids be applied initially to treat the

bleeding trauma patient

Addition of colloids be considered

within the prescribed limits for each solution in
haemodynamically unstable patients
Hypertonic solutions also
be considered during initial treatment

Rossaint et al. Critical Care 2010

Double-blind, randomized controlled trial, single level I trauma center
Blunt trauma and prehospital hypotension (SAP 90 mmHg)
Treatment with 250 mL of 7.5% hypertonic saline and 6% dextran 70
(HSD) vs lactated Ringer solution (LRS)

ARDS-free survival
28-day mortality Massive transfusion
ARDS-free survival

Bulger EM et al. Arch Surg. 2008 Feb;143(2):139-48

Cathterisme artriel et veineux fmoral
Transfuseurs massifs
Massive Transfusion management

Trauma massive transfusion protocol

Predefined number of PRBC, fresh frozen plasma and
platelets
Ratio PRBC/fresh frozen plasma = 1/1-2/1
Improved communications, and enhanced systems
flow to optimize rapid blood product availability
Coagulation monitoring
Trauma exsanguination protocol (TEP): immediate and continued release of blood products
from the blood bank in a predefined ratio of 10 units of PRBC to 4 units of fresh frozen plasma
to 2 units of platelets.

Cotton BA et al., J Trauma. 2008;64:11771183.

Combat support hospital (CSH) in Iraq between November 2003 and September 2005
246 patients with massive transfusion, defined as 10 or more RBC units
(including both stored RBC and fresh whole blood units)

Borgman MA et al., J Trauma. 2007;63:805813

Massive transfusion protocol supporting a 1:1.5 FFP:PRBC ratio, improved communications,
and enhanced systems flow to optimize rapid blood product availability.

Riskin BJ et al., J Am Coll Surg 2009;209: 198205.

 Fibrinogen

Thrombelastometric signs of a functional fibrinogen deficit

or a plasma fibrinogen level of less than 1.5-2.0 g/l

Initial fibrinogen concentrate dose of 3 to 4 g or 50 mg/kg of cryoprecipitate,

which is approximately equivalent to 15 to 20 units in a 70 kg adult

Repeat doses may be guided by thrombelastometric

monitoring and laboratory assessment of fibrinogen levels

Rossaint et al. Critical Care 2010

380 non-trauma patients who received fresh frozen plasma from 2004 to 2005 were compared with 2,058
nontrauma patients who did not receive fresh frozen plasma

Sarani B et al. Crit Care Med 2008; 36:11141118

Multicenter prospective cohort study evaluating clinical
outcomes in bluntly injured adults with hemorrhagic shock

Each unit of FFP was independently

associated with a 2.1% higher risk of
MOF and a 2.5% higher risk of ARDS.

J Trauma. 2009;67: 221230

131 patients / Retrospective analysis included trauma patients who received 5 units
RBC within 24 hours. Coagulation management was guided by thromboelastometry

Fibrinogen concentrate was given as first-line haemostatic therapy when maximum clot
firmness (MCF) measured by FibTEM (fibrin-based test) was <10 mm. Prothrombin complex
concentrate (PCC) was given in case of recent coumarin intake or clotting time measured by
extrinsic activation test (EXTEM) >1.5 times normal. Lack of improvement in EXTEM MCF after
fibrinogen concentrate administration was an indication for platelet concentrate.

Schchl H et al. Crit Care. 2010;14(2):R5

Retrospective analysis included trauma patients who received 5 units RBC within
24 hours. Coagulation management was guided by thromboelastometry

Fibrinogen concentrate was given as first-line haemostatic therapy when maximum clot
firmness (MCF) measured by FibTEM (fibrin-based test) was <10 mm. Prothrombin complex
concentrate (PCC) was given in case of recent coumarin intake or clotting time measured by
extrinsic activation test (EXTEM) >1.5 times normal. Lack of improvement in EXTEM MCF after
fibrinogen concentrate administration was an indication for platelet concentrate.

Schchl H et al. Crit Care. 2010;14(2):R5

Sustain haemostasis targets

Without brain With brain

or spinal injury or spinal injury
Hb = 7 - 9 g/dL

PT, aPTT < 1.5 x N

Fg > 1.5-2.0 g/L

Ionised Ca++ = 1.1-1.3 mmol/l

Normothermia

Plt > 50 x 109 L-1 Plt > 100 x 109 L-1

Randomised controlled trial / 274 hospitals in 40 countries / 20 211 adult trauma patients with, or at risk
of, significant bleeding were randomly assigned within 8 h of injury to either tranexamic acid (loading
dose 1 g over 10 min then infusion of 1 g over 8 h) or matching placebo.

Trauma patients with significant hemorrhage (SAP < 90 mmHg or/and HR > 100 bpm)
or at risk of significant hemorrhage

Lancet. 2010 Jul 3;376(9734):23-32

Randomised controlled trial / 274 hospitals in 40 countries / 20 211 adult trauma patients with, or at risk
of, significant bleeding were randomly assigned within 8 h of injury to either tranexamic acid (loading
dose 1 g over 10 min then infusion of 1 g over 8 h) or matching placebo.

Trauma patients with significant hemorrhage (SAP < 90 mmHg or/and HR > 100 bpm)
or at risk of significant hemorrhage

Lancet. 2010 Jul 3;376(9734):23-32

Recombinant factor VIIa

Massive bleeding
Control of bleeding source
Surgery/embolization/blood products

Bleeding stopped Persistent massive bleeding

Consider rFVIIa
Correct hypothermia/acidosis/hypocalcemia

Administer rFVIIa

Consider after 1h

Bleeding stopped Persistent massive bleeding

Control of bleeding source
Surgery/embolization/blood products

Readminister rFVIIa
Trauma Remplissage vasculaire

Remplissage vasculaire
Restauration de la volmie pour assurer une perfusion tissulaire
Suffisante et prvenir les dysfonctions dorganes

Mais un remplissage vasculaire important peut :

Diluer les facteurs de coagulation et les plaquettes
Provoquer une augmentation excessive de la PA
Induire un risque de syndrme de compartiment
(abdominal membres)
 Time elapsed between injury and
operation has to be minimised

The concept of hypotensive resuscitation avoids

the adverse effects of early aggressive
resuscitation while maintaining a level of
tissue perfusion that, although lower than normal,
is adequate for short periods

Target SAP of 80-90 mmHg (MAP of 60-65 mmHg)

until major bleeding has been stopped
in the initial phase following trauma

Rossaint et al. Critical Care 2010

Trauma Remplissage vasculaire

Remplissage vasculaire
Restauration de la volmie pour assurer une perfusion tissulaire
Suffisante et prvenir les dysfonctions dorganes

Mais un remplissage vasculaire important peut :

Diluer les facteurs de coagulation et les plaquettes
Provoquer une augmentation excessive de la PA
Induire un risque de syndrme de compartiment
(abdominal membres)
Trauma Fluid management

Fluid resuscitation
Restoration of blood pressure and volemia
to sustain tissue perfusion and vital organ function

But early aggressive fluid resuscitation may increase

bleeding:
Dilution of coagulation factors and platelets
Excessive increase in arterial pressure
Risk of compartment syndrome (abdominal members)
Trauma Registry of the American College of Surgeons database
patients with an extremity Abbreviated Injury Scale
(AIS) score 3 abdominal AIS = 0

Secondary abdominal compartment syndrome (ACS)

is the development of ACS in the absence of
abdominal injury

Madigan MC et al. J Trauma. 2008 ;64(2):280-5

Madigan MC et al. J Trauma. 2008 ;64(2):280-5
 Damage control

Suggested damage control

algorithm

Persisting hypotension: Laparotomy and pelvic packing

No primary closure of abdominal wall
Rapid transport to the ICU for continued resuscitation and
correction of metabolic abnomalities
2nd looks with change of tamponades within 24-28 h
Scheduled definitive surgery within the first 2 weeks
Management of trauma hemorrhagic shock

Un trauma center et un rseau

trauma efficients

Importance de mi,imiser le temps entre laccident

et le contrle de lhmorragie

Stratgie hmodynamique base sur de

objectifs
Strategie claire pour lensemble des
intervenants