PHARM Podcast 39 – Haemorrhagic shock in remote settings with the THREE RESUSCITEERS

Dr Casey Parker      Dr Amit Maini             Dr Michelle Johnston

Hi there folks! Another first for the PHARM podcast! A three way interview from across Australia with :

  1. Dr Amit Maini of EDTCC blog
  2. Dr Casey Parker of Broomedocs blog
  3. Dr Michelle Johnston of LITFL blog

What we discuss over the 50 minute session is the current thinking amongst peer Emergency medicine and Critical care providers on how to manage the haemorrhagic shock setting, in particular in remote settings with limited resources.

We tackle the controversies of permissive hypotensive resuscitation in children and head injured patients, the use of vasopressors, the role of crystalloids .  What role does haemostatic resuscitation have and what agents might be helpful? What is the current evidence base for all this?

This month quite fortuitously there have been two great articles from Dr Karim Brohi and co-authors in the British Medical Journal on fluid resuscitation in trauma and the role of tranexamic acid.

My mate Ben Meadley has posted about these articles here on his awesome blog site, HERE : Some papers from the king of trauma

Also there was an excellent presentation on prehospital blood product resuscitation and haemostatic strategies by Dr Stuart Gillon last year.

Major Haemorrhage in the remote and retrieval environment

ANd if you have not already listened to this excellent podcast from EmCrit and Karim Brohi, check it out here!

An interview on severe trauma with Karim Brohi

But THERE IS MORE!

Casey Parker wrote this ripper of a piece on MASSIVE TRANSFUSION PROTOCOL

Stay safe and enjoy the interview! 

Minh

Now on to the Podcast

Right Click and Choose Save-as to Download the Podcast.

19 Comments
  1. Learned a new one recently – how to do your own autotransfusion in a remote/austere setting

    Take lost blood (lets’s assume via sucker from intra-abdominal bleeder) and place in a sterile bowl with sterile gauze

    Then use a sterile plastic saline bottle, inverted, with the bottom cut off. Fill the neck with more gauze and then squeeze the blood-soaked gauze from the bowl into the inverted bottle, to fill it

    Run an IV from the neck of the bottle to the patient

    Et voila! You’ve just autotransfused the patient’s own blood

    Any thoughts on blood donor panels in rural areas?

    • Thanks Tim – the “Primary Surgery” series gives a nice description of this type of improvised cell saving, including the lesser known “Soup Ladle Method”!

      If you do not have these in your library, see http://www.primary-surgery.org/ps/vol1/ch-16.pdf (16.10, pg 241)

      And on the donor panels, whilst probably hard to instigate in a rural town now (although I believe there are still a few around), they remain a very viable option with completely isolated populations, such as on Antarctic bases. In the latter situation they are routine, with personnel screened pre-departure (and ideally again after a few weeks of isolation when any diseases should be out of incubation period).

  2. Tim – you are truly on the cutting edge! We did chat a bit on donor panels – not something I see coming back anytime soon in the current legalese environment.
    What makes sense in science rarely correlates with what happens in reality of our hospitals!
    Casey

  3. Hey Guys,
    love the format Mihn,
    Just one question for Casey you mentioned draining a haemothorax in the case at the rural clinic. I know its quite discriptive but on ATLS the instructors suggested not doing this if you were stuck without blood. Just as there is some tamponading of the bleeding whilst in the chest cavity. Thoughts guys?

  4. Hey Andre – it is thought that the blood in the chest cavity (of a traumatic haemothorax) providing some sort of tamponade is a bit of a myth. It is large volume, but low pressure, certainly not high enough to cause any tamponade effect, so that all a chest full of blood does is impair respiration, and it’s best to drain it by ICC. It’s a bit like the old teaching of clamping the chest tube after the first 1.5L comes out – it probably just makes the doctor feel better (not seeing the blood come out into the bottle) but has no true tamponade effect.
    You can certainly understand the tendency, however, to avoid seeing the blood pouring out, when you don’t have blood to replace it. I am simply not aware of any evidence to suggest that you will reduce the amount of bleeding by leaving it slowly bleeding into the chest, rather than out. In fact, is allowing a lung to reexpand a better physiologic way of attempting to control the bleeding??
    It the patient had a massive haemothorax (large volume initially/ongoing bleeding – numbers a little arbitrary, and depends on many individual circumstances but about 1.5L/250-500ml/hr) then the traditional thought is surgical haemostasis. In the rural setting though, it should be meticulous attentions to blood/factors replacement and prevention of coagulopathy, and rapid transfer to a centre that is capable of cardiothoracic surgery. Love the idea of a MacGyver style cell-saver though, by Tim Leeuwenberg.
    Any other thoughts chaps? In the rural setting?

  5. Agree with Michelle on this, – blood inside chest or blood outside chest is still blood outside the vascular compartment. Probably more to gain from restoring respiratory function by decompression / drainage. Though I must admit my very first chest tube draining a haemothorax was like something from Nightmare on Elm Street – blood everywhere. If you had access to auto transfusion/cell saver (or could rig it up somehow) – great.
    Rural major trauma gives me goose bumps.

    • yes indeed! there is no doubt from an anatomical viewpoint you can exsanguinate into your chest cavity.
      I think this notion of not sticking the ICC chest drain in comes from the old surgical tactic of not opening the belly up until everything is prepared for massive resuscitation.

      Whilst there is little objective evidence to support this, it does seem sensible to not open up a body cavity full of blood until you are in a place where you can initiate massive blood transfusion and have immediate surgical haemostatic capability.

      I think prehospital USS will change how we manage these haemothoraces in the field. if I see lots of blood in the chest on USS and resp status seems ok for now , I might choose to not insert a drain until we retreat to an area with shiny walls and a welcoming blood bank and surgeon. This helps me to realise that minimising transport time in this situation is best and the optimal fluid to use is lots of aircraft fuel to get going ASAP. If resp status is cactus, compromised or Signs of pneumo on uSS as well then you are obliged to drain that cavity and do your best with the bleeding. But you can do this on the way to the surgeon. I have inserted many drains during flight and it depends on your aircraft as to how challenging this might be but it can be done!

      for autotranfusion, it seems logical but be cautious as the blood you are collecting to return is not the same as whats in the vessels. Its defibrinated and lacks clotting factors, its got Hb but thats about it. here is a great overview blog article I found on autotransfusion update in chest trauma..could not find the author but it reads well.
      http://trauma01.wordpress.com/category/autotransfusion/

  6. Hi all,

    A great podcast which raises as many questions as answers…

    I feel I have to point out the elephant in the room in the case scenario of major exsanguinating trauma in the rural clinic. Outside the fluid/blood resuscitation as you describe, if that patient was going to survive, the issue is not really whether to use cryo, factor 7 etc, none of which are going to be available, but to arrange a rapid and appropriate evacuation of the patient to a surgeon who can stop the bleeding. The total transfer time for a 90 minute flight is likely to be in excess of 4 hours minimum, and an early experienced decision needs to be made as to what products to take, and how much delay is acceptable to get those products. O neg blood can usually be taken fairly rapidly (although it may need to be taken from a regional hospital), any other blood products take a surprising amount of time to get from a transfusion lab to an aircraft, and that delay may well be worse for the patient. It’s a difficult decision sometimes, although its always clear in retrospect.

    Likewise, as Minh suggests, sometimes its better to do the best you can on the aircraft rather than spend time on the ground doing procedures that further delay that time to definitive care.

    Would welcome your thoughts,

    Andy

    DOI – Emergency physician and retrieval medic!!

    • thanks Andy
      as you correctly point out the exsanguinating patient needs urgent haemostasis, and if you cant provide it where they are, then getting them to somewhere they can get it is a priority. but as you well know, what do you during those 4hrs involved in the retrieval? This is a product of luck and good prehospital critical care and resuscitative science.
      I had a colleague who was diverted to a remote primary trauma call for a MVA. The patient had haemothorax, flail chest, retroperitoneal bleeding. My colleague had no blood products at all as was diverted to this job. She did RSI, chest drain, gave a total of 7 litres of saline and started a prehospital noradrenaline infusion. Guy survived and left ICU two weeks later.

      Now its politically correct to say, this guy should have gotten lotsof FFP and blood and cryo etc and we should have performed minimal volume resuscitation and noradrenaline makes no sense in haemorrhagic shock, but you know what? awhen this case was presented at a trauma conference, no one said they would have done anything differently!

  7. Hi Andy
    Completely agree with your strategy. In my opening discussion I was trying (in a less than precise manner) to say exactly that – the solution here is to stop bleeding from the vessels / organs that have been disrupted.
    At best : all the factors and perfectly conducted “massive transfusion” with optimised BP etc will result in a coagulopathic, hopefully warm and not too acidotic patient. I read somewhere that giving the 1:1:1 ratio with currently available products is about the same as infusing blood with an INR of 1.7ish and poorly functioning platelets. Just keeping head above water really.

    Surgery (Damage control, minimalist tying and packing the cavity) is what we need.

    Here is the quandary for me as a rural generalist with little major surgery experience – if there was no surgeon within 4 hours and the patient was going downhill – should we attempt “resuscitative surgery” in the remote location?

    Pros: it is the only intervention that is likely to alter the outcome if we get it right.
    Cons: relies on some serious guesswork.

    The alternate is to watch the patient bleed slowly otherwise with close to 100% chance of death.
    In this day and age with smartphones etc – could we conceivably do his over the ether with a trauma surgeon on the line / skype ec – maybe. Burr holes have been done like this in similar situations. Admittedly cardiothoracic surgery bleeding is a bit more complex – however as stated above – the alternative is dire.

    You could also argue it is better to start “surgery” early and not wait for your hand to be forced by crashing vitals – but I think most of us would be more comfortable if it were already a truly life vs. death scenario.
    Casey

    • this is the challenge in remote trauma and in my view the frontier of retrieval medicine. Cliff Reid and others such as London HEMS have adroitly argued that in select cases prehospital resuscitative surgery is lifesaving with good outcomes. It is the ultimate in prehospital critical care.

      A collegue of mine shared a story on another retrieval medicine discussion forum I run..this is a few years ago. She and her colleague were faced with. your ultimate nightmare Casey. Due to a tropical storm, all air evacuations were impossible for twelve hours from their remote hospital. They had a young man who had suffered a probable ruptured spleen on clinical exam after a MVA, he was in shock and probably would not survive the night without surgery. Neither of them had ever done a splenectomy. They rung up the tertiary hospital in their region and were told to consider performing a last ditch laparotomy but it was left to them to decide. They spoke to the family who agreed to consent. They flipped a coin to decide who would do the GA and who would do the cutting. They looked up a textbook along with some notes given to them by the other hospital. It was a two hour operation but my colleague removed the ruptured spleen. Patient survived the night and then discharged himself the next day!

      The Red Cross war surgery manual( freely downloadable from the net) describes a great story of two Ugandan doctors who attended a trauma surgery course run by a Swiss surgeon. After the meeting they asked about a case they had of a MVA trauma patient who had signs of shock and abdominal bleeding. They performed a laparotomy and found a lacerated liver. They did not know what to do so packed the liver and closed the abdomen, expecting the man to die. He survived overnight so they took him back to theatre and removed the packs. He survived. The Swiss surgeon told them they had performed damage control surgery without knowing it!

      that is truly the next area of development for prehospital and retrieval medicine..resuscitative surgery. Teams of prehospital providers who can provide prehospital anaesthesia and critical care as well as cross training in trauma surgery for resuscitation.

      Everyone in resuscitation is expected to know how to perform a surgical airway for obstruction. There was a time not so long ago when we were all expected to be able to perform an appendicectomy, caeserean section etc It is time to reclaim those skills once again…

  8. Love the podcast guys. Seems like the very whisper of crystaloid in any discussion about traumatic volume resus will win you a good finger shaking. Thats all well and good for the docs at the “intergalactic” trauma centres, but what am I to do to temporise a rapidly deteriorating trauma pt, trapped in what used to be a car, three and a half hours from the capital? No crystaloid? A little? To what end? Great to hear a discussion of management in the resource poor environment. Should be more of it.

  9. Jamie, you had better be coming back to Kangaroo Island, we need your skills. However, if it comes to doing an eLap cos the retrieval guys are weathered in, then I’ll do the GA..you can do the cutting….

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out /  Change )

Google+ photo

You are commenting using your Google+ account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s