Welcome to SOVAH Resident's 360!
This is where topics/questions will be posted and residents will need to comment with answers and supporting evidence for their answer. Residents will be required to post their answers and supporting evidence by midnight that evening. The questions will then be readdressed the subsequent morning before rounds in a 15-30 minute conversation.
Sunday, April 16, 2017
Dr. H question:
What are the principles of damage control resuscitation in a patient who is actively bleeding?
Damage control goals can be stated as oxygenation, maintaining cardiac output and tissue perfusion while attempting to achieve a steady metabolic state. Regaining lost blood volume and reinstating euvolemia would be achieved through repair of the vasculature in trauma surgery and admintering fluids in a 1:1:1 ratio of PRBCs to plasma to Platelets; the current literature does not support larger volumes of crystalloid to avoid AKI and acute lung injury. Warming hypothermic patients to > 35 degrees C, providing ventilatory support and laboratory testing to maintiain Ph > 7.2 and Lactate <4 would be prudent in the critical care arena. The goals of Surgical intervention would be geared toward maintenance of hemodynamic status acheived through fluid resusitation and preserving tissue perfusion. (up to date, MTP guidelines, resident 360)
I would start with Airway, breathing, and circulation, History and Physical exam. I would get stat vital signs. 2 large bore IVs. Maintain O2 saturation, Stat CBC,CMP, Coags, DIC work up, Type and screen, order 4 units of blood and FFP to hold
Make sure their INR is not supra therapeutic if so I would give Vitamin K and hold any home Anticoagulation and DVT prophylaxis at this time.
Per Up to date and Resident360 "Clinical practice guideline: Red blood cell transfusion in adult trauma and critical care*":
Resuscitation using intravenous fluids should be used only for hypotensive patients, and then only until blood is available.
Blood products should be given as soon as the need for transfusion is recognized.
Blood products (red blood cells, plasma , and platelets) should be given in equivalent amounts (1:1:1 ratio).
Look for the source is it GI? Do they need a protonix drip or protonix BID and a STAT GI consult? Do they need a stat CT abd/pelvis to look for bleeding in the abdomen? I would absolutely attempt to look for the source of the bleed while stabilizing the patient in case they need to be transferred.
Airway and ventilator support is customarily the initial resuscitation for emergent medical occurrences, however with critical blood loss, fluid resuscitation is equally important. A 1:1:1 RBCs, Plasma and platelet ratio should be administered for volume support to insure proper tissue oxygenation and perfusion. Of course, acute blood loss should be minimized, although, operative time for hemorrhage control should be limited to prevent acidosis and hypothermia. Follow up, definitive repair may occur after stabilization.
1. Stop the bleeding, 2. hypotensive resuscitation, 3 Avoiding overuse of IV fluids 4.Prevention/Correction of acidosis, hypothermia, and coagulopathy.
Resuscitation is primarily focused on early use of a balanced amount of red blood cells, plasma, and platelets.
Coagulopathy is an issue because the clotting factors are being lost. Replacing lost fluids with crystalloid dilutes the remaining blood making coagulation worse. Coagulation is also made worse by acidosis and hypothermia. Acidosis is caused by the increasing lactic acid from anaerobic metabolism due to decreased oxygenation of the tissues. Hypothermia results from the loss of warm blood and worsened by cool IV fluids. Hypothermia inhibits the coagulation factors. According to journal of trauma, volume 60 #4, permissive hypotension would aid in decreasing blood loss by avoiding re-bleeding but maintain perfusion of organs. The article makes the point known that DCR will not be successful unless the bleeding is stopped, mostly via surgery.
First of all I will compress the site of active bleeding with sterile gauze to prevent further bleeding . Then 2 large bore needles in both upper extremities and oxygen supplimentation via nasal cannula . Bolus of 2L of NS will be started asap. I ll place the cardiac monitor and check vitals and map .I will keep the map above 65 . If map is lower , I will also start levophed otherwise only NS. In the meantime, Type and cross match , Hand H and 3 units of PRBC will be ordered. EKG , CBC , BMP will be ordered. Quick history and physical will be done . If only external bleeding, we will continue fluids followed by blood transfusions, tetanus shot and wound suturing and dressing . If chances of internal bleeding, we will do portable Abdominal and pelvic US . If internal bleeding, surgery will be consulted otherwise we will maintain the map above 65 and repeat H and H after blood transfusion .
Damage control goals can be stated as oxygenation, maintaining cardiac output and tissue perfusion while attempting to achieve a steady metabolic state. Regaining lost blood volume and reinstating euvolemia would be achieved through repair of the vasculature in trauma surgery and admintering fluids in a 1:1:1 ratio of PRBCs to plasma to Platelets; the current literature does not support larger volumes of crystalloid to avoid AKI and acute lung injury. Warming hypothermic patients to > 35 degrees C, providing ventilatory support and laboratory testing to maintiain Ph > 7.2 and Lactate <4 would be prudent in the critical care arena. The goals of Surgical intervention would be geared toward maintenance of hemodynamic status acheived through fluid resusitation and preserving tissue perfusion. (up to date, MTP guidelines, resident 360)
ReplyDeleteI would start with Airway, breathing, and circulation, History and Physical exam. I would get stat vital signs. 2 large bore IVs. Maintain O2 saturation, Stat CBC,CMP, Coags, DIC work up, Type and screen, order 4 units of blood and FFP to hold
ReplyDeleteMake sure their INR is not supra therapeutic if so I would give Vitamin K and hold any home Anticoagulation and DVT prophylaxis at this time.
Per Up to date and Resident360 "Clinical practice guideline: Red blood cell transfusion in adult trauma and critical care*":
Resuscitation using intravenous fluids should be used only for hypotensive patients, and then only until blood is available.
Blood products should be given as soon as the need for transfusion is recognized.
Blood products (red blood cells, plasma , and platelets) should be given in equivalent amounts (1:1:1 ratio).
Look for the source is it GI? Do they need a protonix drip or protonix BID and a STAT GI consult? Do they need a stat CT abd/pelvis to look for bleeding in the abdomen? I would absolutely attempt to look for the source of the bleed while stabilizing the patient in case they need to be transferred.
Airway and ventilator support is customarily the initial resuscitation for emergent medical occurrences, however with critical blood loss, fluid resuscitation is equally important. A 1:1:1 RBCs, Plasma and platelet ratio should be administered for volume support to insure proper tissue oxygenation and perfusion. Of course, acute blood loss should be minimized, although, operative time for hemorrhage control should be limited to prevent acidosis and hypothermia. Follow up, definitive repair may occur after stabilization.
ReplyDeletehttps://res-2.cloudinary.com/r360-staging/image/authenticated/s--GUFSRIxB--/v1513096089/tf4rvwetcgaigpmvfatu.png?utm_medium=referral&utm_source=r360&utm_campaign=emergencymedicine
ReplyDelete1. Stop the bleeding, 2. hypotensive resuscitation, 3 Avoiding overuse of IV fluids 4.Prevention/Correction of acidosis, hypothermia, and coagulopathy.
ReplyDeleteResuscitation is primarily focused on early use of a balanced amount of red blood cells, plasma, and platelets.
Coagulopathy is an issue because the clotting factors are being lost. Replacing lost fluids with crystalloid dilutes the remaining blood making coagulation worse. Coagulation is also made worse by acidosis and hypothermia.
Acidosis is caused by the increasing lactic acid from anaerobic metabolism due to decreased oxygenation of the tissues.
Hypothermia results from the loss of warm blood and worsened by cool IV fluids. Hypothermia inhibits the coagulation factors.
According to journal of trauma, volume 60 #4, permissive hypotension would aid in decreasing blood loss by avoiding re-bleeding but maintain perfusion of organs. The article makes the point known that DCR will not be successful unless the bleeding is stopped, mostly via surgery.
First of all I will compress the site of active bleeding with sterile gauze to prevent further bleeding . Then 2 large bore needles in both upper extremities and oxygen supplimentation via nasal cannula . Bolus of 2L of NS will be started asap. I ll place the cardiac monitor and check vitals and map .I will keep the map above 65 . If map is lower , I will also start levophed otherwise only NS. In the meantime, Type and cross match , Hand H and 3 units of PRBC will be ordered. EKG , CBC , BMP will be ordered. Quick history and physical will be done . If only external bleeding, we will continue fluids followed by blood transfusions, tetanus shot and wound suturing and dressing . If chances of internal bleeding, we will do portable Abdominal and pelvic US . If internal bleeding, surgery will be consulted otherwise we will maintain the map above 65 and repeat H and H after blood transfusion .
ReplyDelete