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

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

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

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

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 ± ± ± (62%) 14 ± 24 Delayed resuscitation (n = 289) 92 ± ± ± (70%) 11 ± 19 P value < Bickell, WH et al. NEJM 1994

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 ± ± ± ± 3 14 ± ± 0.17 Delayedresuscitation (n = 289) 12 ± 6 52 ± ± ± ± 2 11 ± ± 0.15 P value 0.02<0.001< Bickell, WH et al. NEJM 1994

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

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

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)

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)

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

A target resuscitation pressure of 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

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

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

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

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 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)

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

Ferrada P et al. J Trauma 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

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

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

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 » »