Documente Academic
Documente Profesional
Documente Cultură
J. Duranteau
Department of Anaesthesia and Intensive Care
Hôpitaux universitaires Paris-Sud
Severe Trauma
This strategy begins from the scene to the emergency room and
continues through the OR and into the ICU
Trauma registry
Multidisciplinary task force
Research program
Rehabilitations facilities
✓ Comparative analysis of data from the Royal London Hospital (RLH) trauma registry and Trauma
Audit and Research Network (England and Wales), 2000–2005
✓ Institution of a specialist trauma service and performance improvement programme
whole-body CT
Senior physician Nurse
Nurse
Junior physician
Extended focused assessment sonography for trauma (eFAST)
Assessment and initial
management of severe trauma
Whole-body CT
Severe trauma
Target SAP 80-90 mmHg until major bleeding has been stopped
Median total
24-hour crystalloid
volume = 4 L in 2011
PRA
Coagulation activation
▪ Procoagulants in the systemic circulation
▪ Impairment of endogenous anticoagulant
activity
▪ Thrombin generation in the systemic
circulation
Hyperfibrinolysis
▪ Acute release of tissue-plasminogen activator
(t-PA)-induced hyperfibrinolysis
▪ Coagulation activation-induced fibrinolysis
Consumption coagulopathy
Trauma-induced coagulopathy
Cause of trauma-induced coagulopathy
The European guideline on management of major bleeding and
coagulopathy following trauma: Fourth edition
✓ Randomized clinical trial (RCT) to test the hypothesis that an MTP goal directed
by TEG improves survival compared with an MTP guided by conventional
coagulation assays (CCA). Gonzalez E.
et al. Injury, Ann Surg 2015
✓ After MTP activation, patients were randomized to be managed either by an MTP
goal directed by TEG or by CCA
The study was terminated early for futility and safety reasons because of the high
proportion of patients in the FFP group who required rescue therapy compared with
those in the CFC group (23 [52%] in the FFP group vs 2 [4%] in the CFC group
Treatment failure was registered if even double-dose study drug administration did not
correct ROTEM pathology or if coagulopathic bleeding persisted at
borderline ROTEM measurements
Reversal of trauma-induced coagulopathy using rst-line coagulation factor
concentrates or fresh frozen plasma (RETIC): a single-centre, parallel-group,
open-label, randomised trial
Bleeding score
▪ 0: no substantial bleeding
▪ 1: injury-related normal bleeding with visible
clots
▪ 2: diffuse microvascular bleeding from wound
and catheter insertion sites
▪ 3: massive bleeding with transfusion of >3 U
red blood cells/h
Massive transfusion
13 [30%] in the FFP group
6 [12%] in the CFC group
OR 3·04 [0·95–10·87], p=0·042)
The European guideline on management of major bleeding and
coagulopathy following trauma: Fourth edition
Brain injury
Pre-HC ER OR ICU
Transcranial
Doppler
PIC
PbtO2
SvjO2