L’hémorragie du polytraumatisé J. Duranteau Hôpitaux universitaires Paris-Sud Université Paris-Sud XI B Vigué.

Présentation au sujet: "L’hémorragie du polytraumatisé J. Duranteau Hôpitaux universitaires Paris-Sud Université Paris-Sud XI B Vigué."— Transcription de la présentation:

1 L’hémorragie du polytraumatisé J. Duranteau Hôpitaux universitaires Paris-Sud Université Paris-Sud XI B Vigué

2 Contrôle de l’hémorragie Restauration d’une physiologie normale Pré-hospitalierBlocRéanimation Mortalité précoce : choc hémorragique non controlé Mortalité tardive : Défaillance d’organes Choc hémorragique traumatique Déchocage

3 Contrôle de l’hémorragie Restauration d’une physiologie normale Pré-hospitalierBlocRéanimation Faible remplissage vasculaire Hypotension permissive Traitement de la coagulopathie Traitement de la dysfonction hémodynamique – objectifs thérapeutiques Choc hémorragique traumatique Déchocage

4 Faible remplissage vasculaire “hypotension permissive” Faible remplissage vasculaire “hypotension permissive” Afin de limiter la dilution des facteurs de la coagulation: Limiter le remplissage vasculaire Tolérer un certain degré d’hypotension artérielle Afin de limiter la dilution des facteurs de la coagulation: Limiter le remplissage vasculaire Tolérer un certain degré d’hypotension artérielle Contrôle rapide du saignement Stratégie de « Damage Control » Contrôle rapide du saignement Stratégie de « Damage Control » Débuter précocément la transfusion de produits sanguins Débuter précocément la transfusion de produits sanguins

5 Before arrival at the hospital Ringer’s lactate (ml) Trauma center Ringer’s lactate (ml) Packed red cells (ml) Survival to discharge Length of hospital stay Immediate resuscitation (n = 309) 870 ± 667 1608 ± 1201 133 ± 393 193 (62%) 14 ± 24 Delayed resuscitation (n = 289) 92 ± 309 283 ± 722 11 ± 88 203 (70%) 11 ± 19 P value <0.001 0.04 0.006 Bickell, WH et al. NEJM 1994

6 Patient care times (min) Transport interval Trauma-center interval Scene SAP (mmHg) Trauma-center Hb (g/dl) Prothrombin time (sec) Arterial pH Immediateresuscitation (n = 309) 13 ± 6 44 ± 65 58 ± 35 79 ± 46 11 ± 3 14 ± 16 7.29 ± 0.17 Delayedresuscitation (n = 289) 12 ± 6 52 ± 99 59 ± 34 72 ± 43 13 ± 2 11 ± 2 7.28 ± 0.15 P value 0.02<0.001<0.0010.42 Bickell, WH et al. NEJM 1994

7 For hypotensive patients with penetrating torso injuries, delay of aggressive fluid resuscitation until operative intervention improves outcome For hypotensive patients with penetrating torso injuries, delay of aggressive fluid resuscitation until operative intervention improves outcome Study results should not be directly extrapolated to All age groups Blunt trauma Longer transport intervals Study results should not be directly extrapolated to All age groups Blunt trauma Longer transport intervals Bickell, WH et al. NEJM 1994

8 Hampton DA et al. PROMMTT Study Group. J Trauma Acute Care Surg 2013 Prospective data from 10 Level 1 trauma centers 1,245 trauma patients; 84% (n = 1,009) received prehospital IVF, and 16% (n = 191) did not Regarding prehospital IVF, the median volume of fluid given to the IVF group was 700 mL (IQR, 300-1,300) Prospective data from 10 Level 1 trauma centers 1,245 trauma patients; 84% (n = 1,009) received prehospital IVF, and 16% (n = 191) did not Regarding prehospital IVF, the median volume of fluid given to the IVF group was 700 mL (IQR, 300-1,300) ED

9 Hampton DA et al. PROMMTT Study Group. J Trauma Acute Care Surg 2013 Prospective data from 10 Level 1 trauma centers 1,245 trauma patients; 84% (n = 1,009) received prehospital IVF, and 16% (n = 191) did not Regarding prehospital IVF, the median volume of fluid given to the IVF group was 700 mL (IQR, 300-1,300) Prospective data from 10 Level 1 trauma centers 1,245 trauma patients; 84% (n = 1,009) received prehospital IVF, and 16% (n = 191) did not Regarding prehospital IVF, the median volume of fluid given to the IVF group was 700 mL (IQR, 300-1,300)

10 Hampton DA et al. PROMMTT Study Group. J Trauma Acute Care Surg 2013 Prospective data from 10 Level 1 trauma centers 1,245 trauma patients; 84% (n = 1,009) received prehospital IVF, and 16% (n = 191) did not Regarding prehospital IVF, the median volume of fluid given to the IVF group was 700 mL (IQR, 300-1,300) Prospective data from 10 Level 1 trauma centers 1,245 trauma patients; 84% (n = 1,009) received prehospital IVF, and 16% (n = 191) did not Regarding prehospital IVF, the median volume of fluid given to the IVF group was 700 mL (IQR, 300-1,300)

11 Effects of different target MAPs (40, 50, 60, 70, 80, and 100 mmHg) on uncontrolled hemorrhagic shock Normotensive groups (80 and 100 mmHg) had increased blood loss (101%, 126% of total blood volume) LI T et al. Anesthesiology 2011

12 A target resuscitation pressure of 50-60 mmHg is the ideal blood pressure for uncontrolled hemorrhagic shock. Ninety minutes of permissive hypotension is the tolerance limit LI T et al. Anesthesiology 2011

13 Effect of norepinephrine during resuscitation of uncontrolled hemorrhagic shock in mice Blood loss at T90 (µL) Harrois et al. ESICM 2012

14 Effect of norepinephrine during resuscitation of uncontrolled hemorrhagic shock in mice Villous perfused density in each group (% ± SEM) Harrois et al. ESICM 2012

15 Dutton RP et al., J. Trauma. 2002;52:1141-1146. Titration of initial fluid therapy to a lower than normal SBP during active hemorrhage did not affect mortality

16 Spahn et al. Critical Care 2013 Time elapsed between injury and operation has to be minimized Time elapsed between injury and operation has to be minimized Concept of low volume fluid resuscitation Permissive hypotension Concept of low volume fluid resuscitation Permissive hypotension Target SAP 80-90 mmHg until major bleeding has been stopped in the initial phase following trauma MAP ≥80 mmHg in patients with combined haemorrhagic shock and severe TBI (GCS ≤8) MAP ≥80 mmHg in patients with combined haemorrhagic shock and severe TBI (GCS ≤8)

17 Estimation du débit cardiaque à partir de la courbe de pression artérielle Doppler Oesophagien Polytraumatisme - Hémodynamique Parasternale grand axe Parasternale petit axe Apicale quatre cavité et sous-xyphoïdienne

18 Ferrada P et al. J Trauma. 2011 53 patients admitted to trauma critical care units The FREE was performed by an ultrasonographer or an intensivist and interpreted by an intensivist using a full service portable echo machine The views obtained are the parasternal long axis (PLA), parasternal short axis (SA), and apical four-chamber and subxiphoid (SX) windows 53 patients admitted to trauma critical care units The FREE was performed by an ultrasonographer or an intensivist and interpreted by an intensivist using a full service portable echo machine The views obtained are the parasternal long axis (PLA), parasternal short axis (SA), and apical four-chamber and subxiphoid (SX) windows Parasternal long axis window Parasternal short axis window Apical four-chamber window Subxiphoid window

19 Hypotensive patients in the trauma bay Views obtained included parasternal long and short, apical, and subxyphoid Results were reported regarding contractility (good vs. poor), fluid status (flat inferior vena cava [hypovolemia] vs. fat inferior vena cava [euvolemia]), and pericardial effusion (present vs. absent) LTTE teaching entailed 70 minutes of didactics and 25 minutes of hands-on Limited transthoracic echocardiogram (LTTE) 52 patients Average time for LTTE was 4 minutes 38 seconds. Cardiology-performed TTE was obtained in all patients, and correlation with LTTE was 100% In 29 patients the FREE changed the plan of care: 10 (34%) fluid overload (withholding fluid) 13 (45%) fluid depletion (fluid resuscitation) 3 (10%) depressed cardiac function (inotropes) 3 (10%) low SVR Results Ferrada P et al. J Trauma. 2011

20 Choc Hémorragique traumatique Remplissage vasculaire Buts de Pression artérielle Absence de TC grave 80 ≤ PAS ≤ 90 mmHg Absence de TC grave 80 ≤ PAS ≤ 90 mmHg Présence de TC grave (GCS ≤8) PAS ≥ 120 mmHg Présence de TC grave (GCS ≤8) PAS ≥ 120 mmHg Echec de maintien de la PAS Administration précoce vasopresseur Noradrénaline Débuter à 0.1  g/kg/min Administration précoce vasopresseur Noradrénaline Débuter à 0.1  g/kg/min Titration du remplissage vasculaire Indices de précharge dépendance (ΔPP, ΔIVC, ΔITV) Débit cardiaque Lactate Titration du remplissage vasculaire Indices de précharge dépendance (ΔPP, ΔIVC, ΔITV) Débit cardiaque Lactate Priorité : Arrêter le saignement Priorité : Arrêter le saignement Contrôle du saignement chirurgical et/ou embolisation Contrôle du saignement chirurgical et/ou embolisation Evaluation de la fonction ventriculaire Appréciation visuelle de la FEVG et du VD Evaluation de la fonction ventriculaire Appréciation visuelle de la FEVG et du VD

21 C. Laplace C. Ract P.E. Leblanc G. Cheisson A. Harrois S. Figueiredo S. Hamada S. Tanaka B. Vigué J. Duranteau C. Laplace C. Ract P.E. Leblanc G. Cheisson A. Harrois S. Figueiredo S. Hamada S. Tanaka B. Vigué J. Duranteau Service d’Anesthésie-Réanimation Hôpitaux universitaires Paris-Sud Université Paris-Sud XI Service d’Anesthésie-Réanimation Hôpitaux universitaires Paris-Sud Université Paris-Sud XI « Change starts with one person standing up and saying « no more » » « Change starts with one person standing up and saying « no more » »