Maged Andrews, M.B.B.Ch. (center), leads a PBLD discussion about the treatment of patients with traumatic injuries.
Coagulopathy following traumatic injury is a threat to patients and a challenge for physician anesthesiologists, but treatment refinements — some learned from the military — are making a difference. A few of these advances were explored in a Problem-Based Learning Discussion Tuesday.
The starting point in treatment for the anesthesiologist is still the ABCs — checking the airway, breathing and circulation — said Maged Andrews, M.B.B.Ch., Assistant Professor of Anesthesiology at the University of Maryland School of Medicine. He was the moderator of “Looking for Clots in All the Right Places: Trauma-Induced Coagulopathy.”
However, the trauma patient will quickly need fluids. Dr. Andrews said that a poor choice is normal saline. “It is anything but normal. It has more salt than 25 bags of chips. Five liters of normal saline can make a patient hypothermic and acidotic, so try to avoid normal saline.”
The next issue is dealing with blood, especially if there is traumatic brain injury.
“The military is giving fresh, whole, warm blood off the bat,” he said. “It has platelets, is fully active and everything is working. If you have that option, you also need to have the volume or it is not justifiable.”
While many surgeons will resist, it is best to also keep the patient warm by any means, including blankets, even though warm fluids are better. “Hypothermia plays a huge role in coagulopathy,” Dr. Andrews said. “Do your best because it is a huge thing.”
Another challenge is that many trauma patients have pelvic fractures, but surgeons often want to move the pelvis. “Say ‘Stop, do not touch,’” he said. “A pelvic binder should be properly placed.”
Another concept that has been advanced by the military is damage control resuscitation (DCR), a strategy that targets the conditions that exacerbate hemorrhage in trauma patients.
“It’s the same idea as a sinking boat — you think about plugging the hole any way you can until you catch up. Then, you fix what you have to fix,” Dr. Andrews said.
Because the majority of trauma patients initially present with normal or pro-thrombotic coagulation profiles, those with serious injuries are likely to appear to have hypocoagulability, accelerated fibrinolysis or both. Standard laboratory tests such as PT, PTT, INR, fibrinogen level and platelet count are poor predictors of clinical bleeding, but are adequate for targeted hemostatic resuscitation. However, new monitoring technologies such as TEG® and ROTEM® are superior for detecting relevant hemostatic abnormalities in trauma and surgical patients with massive bleeding, Dr. Andrews said.
