Managing active hemorrhage is a particular challenge to the anesthesiologist due to derangements in hemodynamics, coagulopathy and electrolytes. These are further complicated by anesthesia, operational exposure and the need for intravascular volume support during resuscitation. In addition, the anesthesiologist must attempt to prevent post-operative morbidity, especially concerning end-organ dysfunction in patients with at-risk cardiovascular, neurovascular, pulmonary, hepatic or renal function.
With an aging population, higher use of anticoagulants and the development of novel drugs, a new degree of coagulopathy has been introduced previously unseen in resuscitation1. Historically, initial resuscitation centered on the use of …show more content…
Trauma patients transferred from the field often receive crystalloid infusion. In an analysis of 8700 patients of the German Trauma Registry in 2006, 34% were overtly coagulopathic at the time of presentation; the degree of derangement was proportional to the degree of prior crystalloid resuscitation4. Specifically, 10% of patients were coagulopathic after receiving 500 mL or less of crystalloid, which has been shown to be a product of both acute trauma response and factor dilution4. In trauma, abnormal coagulation panels at the time of presentation are associated with a 3-fold increase in mortality. Specifically, patients presenting with INR >1.5 have a mortality of 30% compared to 5% in those with normal INR4. Further research shows that factor-depleted infusions potentiate coagulopathy of trauma5.
MT is defined as > 10 u RBC in 24 h, > 4 u RBC in 4 hours with additional anticipated need, or replacement of 50% total blood volume (TBV) in 3 hours1. Of patients admitted to a civilian level I trauma center, 1- 5% require a MT1,4. An increase in transfusion requirement is associated with increased mortality. Patients receiving 10 u RBC1. Current evidence for MT practice stems from the past 15 years of research from military trauma literature and has been widely accepted for use in civilian trauma, obstetric emergencies, and major surgery.
Interpreted clinically to represent impending death, the lethal triad of
The market of human blood transfusions is broken down into different uses: Elective Surgery, Emergency Surgery and Trauma. However, Hemopure seems to be suitable only for trauma cases due to its characteristics and, again, high price. To understand the reason, it is important to notice that, actually, only 10% of the 500,000 trauma victims receives RBCs “in the field” or at the site of accident, and the remaining 95% of these people does not receive transfusions until they arrive at the hospital. This delay was often cited as a major factor to the 20,000 trauma deaths. Therefore, since the expected market share for Biopure is 25% and assuming that the total blood transfusions remain stable, the potential market size for Hemopure is approximately $350,000,000. This size is based on an average price of $700 multiplied by 2,000,000 units (around 4 blood units are needed for each Trauma case).
Resuscitation in the ED. Rapid Quantitative resuscitation is recommended in all patients with tissue hypoperfusion. According to the SSC guidelines, the goals of fluid resuscitation include a CVP of 8-12 mm Hg, a MAP > 65 mm Hg, urine
Hemorrhages, or internal bleeding, account for a large portion of deaths in the world. Hemorrhages are an extremely life threatening injury that require immediate medical attention. These injuries are extremely sensitive to the time of injury and the time it takes for surgery to begin. Hemorrhages fall into two main categories: non-compressible and compressible. Compressible hemorrhages can be treated with external compression, tourniquets, and dressings. Non-compressible hemorrhages can not be treated with these techniques, because the injury is usually deep inside the abdominal part of the body and either not visible, or not within reach. This makes non-compressible hemorrhages much more challenging to treat.
Furthermore, prompt infusion of antimicrobial agents ought to be priority and this may require extra vascular access ports (Dellinger, et al., 2008). Early goal-directed resuscitation has confirmed to improved survival for emergency department patients presenting with septic shock in a randomized, controlled, single-center study. Resuscitation lessen 28-day death rate (Dellinger, et al., 2008). In a reviewed conducted by Dellinger, et al., (2012) advocated administering one litre of crystalloid or 300-500ml of colloid more than 30 minutes, to accomplish a central venous pressure (CVP) of 8 mm Hg to 12 mm Hg. Volumes ought to be increased if there are huge indications of hypoperfusion (Dellinger, 2014).
Over the past 11 years to date, the United States has endured almost 8000 casualties from two major conflicts (iCasualties.org, 2012). Although this number is staggering, we have also seen soldiers surviving injuries that were previously fatal (Philpott, 2005). This increase in survivability is largely due to the advancements in medical research and applied training. When it comes to military trauma, our warrior medics should be equipped with the most realistic training attainable. Although several simulation aids are used to provide this training, other methods such as live tissue training are still employed. In
Kleinpell, Aitken, and Achorr 2013, recommend that crystalloids solutions, such as normal saline and lactated ringers, or albumin, should be the fluids of choice when initiating fluid resuscitation. Their recommendation is based on a study trial that was conducted to evaluate the effectiveness of artificial colloids. The results indicated no survival benefits when using artificial colloids comparing to crystalloids (Kleinpell, Aitken, and Achorr 2013).
All over the world, with every new war breaking out, new medical innovations came with it. With each fatal injury incurred on soldiers it was up to surgeons to come up with effective solutions. According to most experts at the time of WW11 stopping the bleeding was in quote "the most vital step" to buy time for the soldier to recuperate and survive, better limb amputation methods led to significantly decreased deaths because of shock or bleeding out. Even today, in specific times in particular during the Afghan war, American medics brought into life new clotting agents that gave the injured more time to get full treatment at a hospital. Another tool that at first was frowned upon by medics
For decades prehospital providers have been treating trauma patients by initiating intravenous access and administering crystalloid fluids. The debate has been over what crystalloid fluid to administer for volume replacement, at what amount, and if we should be administering fluids at all. Many products are available and much research has been conducted with results showing that not all fluids are created equal. Some products have the ability to replace volume but provide little more benefit and may actually be harmful. Other products, when administered at much lower volumes, provide far greater benefits and greater potential for a positive outcome for the patient. Most ground ambulances carry Sodium Chloride 0.9% (Normal Saline) even though all research shows that its performance is inferior in comparison to other fluids. In this paper we will look at several recent studies, in which the effects of fluid administration/volume replacement in hypovolemic trauma patients are measured, with a concentrated look at normal saline.
“After a traumatic injury, hemorrhage is responsible for 35% of pre-hospital deaths and over 40% of deaths within the first 24 hours” (NTI, n.d.). I have worked in an intensive care unit and on a flight team. During my time as a nurse, I have cared for many patients following trauma. While working on the flight team, I became acquainted with tranexamic acid (TXA) for trauma patients who were actively, or highly suspected of, bleeding. I was familiar with TXA for post-operation coronary bypass patients, but not for trauma patients.
Disseminated intravascular coagulation (DIC) is an acquired syndrome that occurs when a stimulus pathologically activates intravascular coagulation and fibrinolysis resulting in an unbalanced hemostasis (Cunningham, 1999; Huether & McCance, 2008; Wada, 2008). The initiation of DIC starts with the release of tissue factor (TF) by the endothelial cells or white blood cells (WBCs). TF are present on many different cell types including lungs, brain, and placenta. The release of TF is subsequent to a variety of causes including trauma, ischemia, excessive metabolic stress, tumors, infectious organisms, exposure to cytokines and endotoxins (Baglin, 1996; Vinay, Abul, Nelson, & Richard, 2007). The release of endotoxin is the means by which
This organ system has a number of functions namely, to keep a constant body temperature as well as to ensure coagulation occurs specifically at the site of injury, as well as to ensure no added blood loss occurs to cause life-threatening effects. This process of blood coagulation is explained in three interconnected phases. In the first phase, the enzyme thrombokinase is activated due to the damage of tissue and the breaking down of platelets. Prothrombin is converted into thrombin by the disintegration of the thrombocytes, electrically charged calcium ions and other coagulation factors, as well as the blood activator and tissue activator which become involved in the coagulation process. The second phase includes production of the thrombin that transforms fibrinogen in the blood plasma into fibrin. The thrombus (or blood clotting) is formed by a fibrilliform mesh that encloses the blood cells. Lastly, the third phase, which takes place as retraction occurs of the fibres of the fibrin mesh. Solidification of the fibrous mesh takes place which closes the defect in the vascular wall. Coagulation is then followed by fibrinolysis (re-dissolution of the clot).
Of course transfusion was associated with haemoglobin criteria on admission (p=0.001), and the quantity of packed red cells given was also associated with haemoglobin grouping on admission (p70 g/L that received blood transfusions for upper GI bleeding, suggesting that some physicians are initiating blood transfusions with a more liberal strategy in some circumstances. Given the recent evidence finding that blood transfusions can contribute to increased morbidity and mortality in patients, there are grounds for this audit to be expanded and continued to determine the results of a fuller and in-depth cohort to understand the reasons behind liberal strategies for initiating blood
Massive hemorrhage is a leading cause of preventable death amongst both civilian and military populations (Abramovich et al., 2013). Pre-hospital care for trauma patients with massive hemorrhage mainly focuses on bleeding control and rapid transport (Hafen, Karren, & Mistovich 2013), but recent studies on the use of tranexamic acid (TXA) as an “anti-clot buster” have sparked interest in development of protocols allowing pre-hospital administration of the drug by EMS agencies in treatment for traumatic hemorrhage (Fox 2016). As an antifibrinolytic drug, TXA works to inhibit the breakdown of clots and reduce blood loss in trauma patients to fight the onset of hemorrhagic shock (Dubose et al., 2012). Following massive trauma, the body’s coagulative response works to promote normal clotting but this process is highly influenced by fibrin breakdown, which works to break down the clots formed as products of coagulation. In patients with hyperfibrinolysis, increased clot breakdown can lead to fatal bleeding and organ failure (Fox 2016). Use of TXA in such patients can potentially work to enhance clot formation and reverse this enhanced fibrinolytic process but studies are being done to prove its benefits in trauma patients with normal fibrinolytic responses as well. Although it was first approved by the FDA in 1986 for treating hemophiliac patients during oral surgery and has been used for decades in cardiovascular surgery to reduce blood loss (Fox 2016), the use of TXA in
Exclusion criteria for the study included: Patient refusal to consent (absolute), infection in the patients back near the proposed site of the injection, coagulation disorder :-( defined as PT: > 18 sec, PTT: >40 sec, I.N.R: > 1.5, clotting time: >8 min, platelet disorder: platelet count: < 100.000, bleeding time: >4 min, HELLP Syndrome: - (defined as Hemolysis, Elevated Liver enzymes, Low Platelet count), receiving any anticoagulant drugs, preexisting neurological disease or psychic patients, history of cardiac and respiratory system failure, known allergy to local anesthetics drugs, coexisting renal disease and eclamptic patients.
In addition, ClotX utilizes existing autoinjector technology that administers soluble clotting factors intramuscularly. This autoinjector technology is most commonly known for its use as a drug delivery system for epinephrine but has never been utilized for the administration of a coagulant agent. While current products exist in the marketplace for the intravenous injection of procoagulant supplements, such as synthesized fibrinogen and factor VIIa (NovoSeven), the intravenous route has posed an obstacle to accessibility in that injections cannot be readily administered in emergencies. As such, the intravenous delivery method is unsuitable for many use cases regarding emergency hemostasis. On the contrary, numerous benefits