Management of traumatic bleeding. Prof Karim Brohi, London [2A02, 2A05, 2C04]
- Major trauma haemorrhage associated with 50% mortality at 1 year. Early deaths – you didn’t stop the bleeding, late deaths you didn’t resuscitate them well enough.
- People are still dying from early exsanguination.
- Early goal is to stop bleeding and maintain haemostatic competence. Maintain basal cerebral & coronary perfusion only. Not targeting base deficit, lactate or a target SBP.
Four pillars of management
- Early haemorrhage control: rapid transit to DCS/IR/tourniquets/REBOA
- Permissive hypotension
- Limit fluid infusions: all fluids inc. PRC dilute coagulation factors. Avoid all crystalloids/colloids whilst bleeding.
- Target coagulopathy: fibrinogen, fibrinogen, fibrinogen….
- Two types of coagulopathy: traumatic & iatrogenic.
- 25% of patients have a traumatic coagulopathy (ATC) with associated 25% mortality. By the time the PT is elevated you are already miles behind the disease process.
- ATC is not a deficiency in coagulation factors but rather fibrinogen loss due to fibrinolysis. Trauma patients present with fibrinogen levels at 50%.
- After 8 units PRC, you will have no fibrinogen! Keep fibrinogen > 2.0. TXA to minimise fibrinolysis.
- Give 1:1:1 to avoid the administration of crystalloid. Crystalloid undoes all the beneficial effects of major trauma packs.
- iTACTIC study on the use of TEG/ROTEM awaited [http://www.tacticgroup.dk/%5D]
Trauma Team Leadership. Dr Caroline Leech, Coventry [1I02, 1I03, 2C01]
- What can trauma teams (which are unique) learn form other teams.
- One key element is practice; in situ simulation may be the answer to practice and develop marginal gains. A 1% improvement becomes significant over time. Also develop shared mental models and implicit knowledge.
- From the prehospital environment we have learnt that task completion increases with the use of names. Why not add names to the trauma tabbards?
- Avoid individual briefings prior to trauma calls and do not get complacent – you will lose the mental model and shared goal.
- Checklists are really helpful!
- Tiered responses help avoid fatigue for recurrent trauma call attendance when not needed.
- Make attendees to the trauma call welcoming. Introduce, check names etc.
- Ensure that we have a shared mental model – update with briefings.
- What makes a good trauma team leader? Common themes include excellent communication, directive with orders and good briefings.
- Closed communication: Call out, check back, closed loop. Precise instructions with clear directions.
- Need to reflect on your leadership style as a trauma team leader.
- Video debriefing useful to review leadership style.
- Peer review also of value for both technical and non-technical skills.