Prehospital Hemorrhage Control and Resuscitation
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1 Prehospital Hemorrhage Control and Resuscitation John B. Holcomb, MD, FACS Professor of Surgery Chief, Division of Acute Care Surgery Director, Center for Translational Injury Research University of Texas Health Science Center Houston, TX 1
2 Disclosures Founder and on the board of Decisio Health The PROPPR Study was Funded by NIH DoD funded for prehospital multicenter transfusion study Receive royalties for c0-inventing a Junctional tourniquet 2
3 Bottom Line Up Front Hemorrhage is the leading potentially preventable cause of trauma death Crystalloid resuscitation increase blood loss, transfusion requirements and death Balanced blood product resuscitation decreases blood loss, transfusion requirements and improves survival Plasma as the primary resuscitation fluid Must have thawed/liquid plasma in the ED or prehospital to really do this well Time is critical 3
4 J Trauma, Rapid progress in trauma care occurs during a war. Damage control resuscitation addresses diagnosis and treatment of the entire lethal triad immediately upon admission. 4
5 DCR components Stop bleeding Hypotensive resuscitation Minimize crystalloid Use plasma to resuscitate patients Increased platelet use Reverse hypothermia and acidosis Hemostatic adjuncts 5
6 Hemorrhage Control Resuscitation is much easier (or only possible) when bleeding is controlled External compression Tourniquets Junctional Truncal Hemostasis Operative (Run faster) New? 6
7 TXA 7
8 Effective Improvised Tourniquet Somalia
9 A Preventable Death: 2003 The casualty was wounded by an RPG and sustained a traumatic amputation of the right arm and a right leg wound. He bled to death from his leg wound despite the placement of three improvised tourniquets. What could have saved him C.A.T. Tourniquet TCCC training for all unit members *Note: Medic killed at onset of action 9
10 CAT x 2 applied by non medics By 2005 almost all casualties present with CATs on Saving lives and limbs Easy and fast to use by non medical personnel Few if any improvised tourniquets 10
11 Demographics of Tourniquet J Trauma, Feb 08 Study Data from patients 220 males ages: 4 70 median limbs 428 tourniquets Conclusion CAT is highly effective and safe 11
12 CAT tourniquet and Combat Gauze Houston, 2008
13 Houston Hemorrhage Control Achieved with Blended Funding: Philanthropy Hospital - RAC Damage Control Resuscitation in Hospital Tourniquets on Helicopters Thawed Plasma and RBCs in the ED Liquid Plasma, RBCs and ultrasound on Helicopters tourniquets on each of the 600 ground ambulances Tourniquets and 1 Combat Gauze on all 5000 uniformed Houston Police Officers Junctional Tourniquets on Helicopter Liquid Plasma and RBCs in the ED in Level 3 trauma centers Planning for plasma and RBCs on select ground units 13
14 2013 Laceration to ulnar artery treated at scene by police officer
15 Civilian patient - LUE traumatic amputation - Treated with manual compression by immediate responder then CAT and blood products by flight medics -Home in 5 days 15
16 Junctional Hemorrhage 16
17 J trauma patients were screened. 324 did not meet criteria 44 subjects died before informed consent 25 subjects declined to participate 11 subjects were excluded for other reasons 21 recently deceased subjects were successfully enrolled in the study across three sites 17
18 Which would you rather have? Resuscitative Thoracotomy REBOA
19 J Trauma, accepted 19
20 REBOA vs ED Thoracotomy 20
21 21
22 JSOM 2014 The resuscitation fluids of choice for casualties in hemorrhagic shock are (in priority order): whole blood, plasma, RBCs and platelets in 1:1:1 ratio; plasma and RBCs in 1:1 ratio; plasma or RBCs alone; Hextend; crystalloid (lactated Ringer s or Plasma-Lyte A). 22
23 How do you make early blood products happen? Work with the Blood bank and Donor Center O- RBCs in the ED and prehospital AB or A plasma in the ED and prehospital Thawed or Liquid plasma Platelets in the ED and prehospital Prehospital and in the ED 23
24 Prehospital and Hospital No distinction Should be a seamless continuum What works in the hospital should be used prehospital Not slow down transport Basic premise of EMS 5000 Hospitals 1852 trauma centers 50,000 ambulances 24
25 PreHospital Blood Products PreHosp Em Care 2014 Prehospital plasma and RBC transfusion was associated with improved early outcomes, negligible blood products wastage. Similar to the data published from the ongoing war, improved early outcomes are associated with placing blood products prehospital. Thousands of units flown, > 300 patients transfused 1.9% wastage 20% transfusion rate
26 Houston LifeFlight Capability Services 150-mile radius, 3000 missions/yr RNs and EMT-P Advanced capabilities: Tourniquets and hemostatic dressings Junctional hemorrhage control devices Pre-hospital plasma and RBCs use Ultrasound diagnostics Portable blood warmers LVAD, ECMO New technology Utilized first in the ED by trauma surgeons. If successful, then on LifeFlight
27 Liquid Plasma and RBCs are the Primary Resuscitation Fluids Pre-Hospital 27
28 Base Station (x4) Refrigerator 28
29 Plasma and RBCs, prehospital, ED and OR Several centers have platelets in the ED Balanced blood product resuscitation of bleeding patients is our standard of care 29
30 Ann Surg 2013 Screened 1695 Enrolled
31 Pre Hospital resuscitation? Seems like a consensus is to start in the hospital with 1:1:1 Why not start this prehospital? 3 bags storage Whole blood? 1 bag.. storage 31
32 Ongoing Study PROHS: Prehospital Resuscitation on Helicopter Study RBC and/or FFP vs Crystalloid 9 US Level 1 trauma centers 5 with blood products prehospital 4 with crystalloid Prospective and observational Improved arrival status? Improved early survival? Enrolled 699 patients since Jan 21% prehospital transfusion rate 32
33 Enrollment Enrolled 699 patients since Jan % prehospital transfusion rate 33
34 PROHS Solid framework within which to design and execute a prehospital trial Ethical and pragmatic approach to future study design 34
35 Different Dried Plasmas Several US companies working on dried plasma Other ProCoagulant Productss
36 Way Forward Stop bleeding ---- devices Extremity Junctional truncal Optimal resuscitation Prehospital and hospital Improved survival Decreased complications (morbidity) 36
37 Thank You
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