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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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:

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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

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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

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