PREHOSPITAL MONITORING OF COAGULATION
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1 NORWEGIAN AIR AMBULANCE PREHOSPITAL MONITORING OF COAGULATION Jostein S. Hagemo Research Fellow, Norwegian Air Ambulance Foundation Anaesthesiologist, Oslo University hospital and Stavanger University Hospital Solstrand, June 19 th 2012
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4 ACUTE TRAUMATIC COAGULOPATHY
5 ACUTE TRAUMATIC COAGULOPATHY
6 ACUTE TRAUMATIC COAGULOPATHY
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8
9 PREHOSPITAL COAGULATION MONITORING
10 PREHOSPITAL COAGULATION MONITORING Must have something to offer, given a positive result
11 PREHOSPITAL COAGULATION MONITORING Must have something to offer, given a positive result
12 PREHOSPITAL COAGULATION MONITORING Must have something to offer, given a positive result
13 PREHOSPITAL COAGULATION MONITORING Must have something to offer, given a positive result Identification of method and a threshold for initiating treatment
14 PREHOSPITAL COAGULATION MONITORING Must have something to offer, given a positive result Identification of method and a threshold for initiating treatment
15 PREHOSPITAL COAGULATION MONITORING Must have something to offer, given a positive result Identification of method and a threshold for initiating treatment Time gain to start of treatment versus time stolen for the analyses
16 PREHOSPITAL COAGULATION MONITORING Must have something to offer, given a positive result Identification of method and a threshold for initiating treatment Time gain to start of treatment versus time stolen for the analyses
17 PREHOSPITAL COAGULATION MONITORING Must have something to offer, given a positive result Identification of method and a threshold for initiating treatment Time gain to start of treatment versus time stolen for the analyses Accuracy
18 PREHOSPITAL COAGULATION MONITORING Must have something to offer, given a positive result Identification of method and a threshold for initiating treatment Time gain to start of treatment versus time stolen for the analyses Accuracy
19 PREHOSPITAL COAGULATION MONITORING Must have something to offer, given a positive result Identification of method and a threshold for initiating treatment Time gain to start of treatment versus time stolen for the analyses Accuracy Feasibility
20 ACUTE TRAUMATIC COAGULOPATHY Must have something to offer - a possibility to differentiate treatment Even in-hospital trials struggle to demonstrate a survival effect in trauma Octaplas/FFP Cryo Dried Plasma Fibrinogen Concentrate NovoSeven PCC Tranexamic Acid Dried Platelets Factor XIII concentrate (FWB)
21 PT/INR
22 Could PT/INR really be suitable for detecting coagulopathy in trauma? Old, cheap, boring, makes no sexy graphs Actually developed to check whether little old ladies take their warfarin INR: INR:
23
24 ACOTS
25 ACUTE TRAUMATIC COAGULOPATHY
26 ACUTE TRAUMATIC COAGULOPATHY
27 ACUTE TRAUMATIC COAGULOPATHY
28 Limitsof agreement: to 0.26
29 APTT
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31 Sensitivity for apptt to detectcoagulopathy in trauma is significantlylowerthan for PT/INR (50% vs 84%) - Yuan Thromb Res. 2007;120(1): Epub 2006 Aug 2.
32 Sensitivity for apptt to detectcoagulopathy in trauma is significantlylowerthan for PT/INR (50% vs 84%) - Yuan Thromb Res. 2007;120(1): Epub 2006 Aug 2.
33 FIBRINOGEN
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40 FUNCTIONAL ASSAYS
41 TEG 5000 RoTEM Delta
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47 TEG and RoTEM are apparently not directly interchangeable. Operator skill and environment may affect accuracy
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49 DOES IT REALLY ADD ANYTHING?
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54 Coagulopathy is not directly proportional to hypoperfusion. Type of injury affects the type and magnitude of coagulation defect.
55 FEASIBILITY
56
57 POC Prehospital tests
58 POC Prehospital tests
59 POC Prehospital tests Sample type Plasma based assays may not be feasible Capillary blood Hypoperfusion Whole Blood
60 Weight Solidity EMI issues
61 Temperature Altitude Humidity
62 IN CONCLUSION
63 PREHOSPITAL COAGULATON MONITORING It is possible! Potentially adds information that is vital to the choice of treatment strategy Currently PT/INR is in the lead More devices in the pipeline Need to define interventions documentation on outcome
64 . Thank you
65
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