L’hémorragie du polytraumatisé

1. L’hémorragie du polytraumatisé J. Duranteau Hôpitauxuniversitaires Paris-Sud Université Paris-SudXI B Vigué

2. Choc hémorragique traumatique Pré-hospitalier Déchocage Bloc Réanimation Restauration d’une physiologie normale Contrôle de l’hémorragie

3. Choc hémorragique traumatique Pré-hospitalier Déchocage Bloc Réanimation Restauration d’une physiologie normale Contrôle de l’hémorragie

4. Faibleremplissagevasculaire “hypotension permissive” • Afin de limiter la dilution des facteurs de la coagulation: • Limiter le remplissagevasculaire • Tolérerun certain degréd’hypotensionartérielle Contrôle rapide du saignement Stratégie de « Damage Control » Débuter précocément la transfusion de produits sanguins

5. Bickell, WH et al. NEJM 1994 Beforearrivalat the hospital Ringer’s lactate (ml) Trauma center Ringer’s lactate (ml) Packedredcells(ml) Survival to discharge Length of hospitalstay 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 <0.001 <0.001 0.04 0.006

6. Bickell, WH et al. NEJM 1994 Patient care times (min) Transport interval Trauma-center interval Scene SAP (mmHg) Trauma-center SAP (mmHg) Hb (g/dl) Prothrombin time (sec) Arterial pH Immediate resuscitation (n = 309) 13 ± 6 44 ± 65 58 ± 35 79 ± 46 11 ± 3 14 ± 16 7.29 ± 0.17 P value 0.02 <0.001 <0.001 0.42 Delayed resuscitation (n = 289) 12 ± 6 52 ± 99 59 ± 34 72 ± 43 13 ± 2 11 ± 2 7.28 ± 0.15

7. Bickell, WH et al. NEJM 1994 For hypotensive patients withpenetratingtorso injuries, delay of aggressivefluidresuscitation untiloperative intervention improvesoutcome • Study results should not be directly extrapolated to • All age groups • Blunt trauma • Longer transport intervals

8. Hampton DA et al. PROMMTT StudyGroup. J Trauma Acute Care Surg2013 • Prospective data from 10 Level 1 trauma centers • 1,245 trauma patients; 84% (n = 1,009) receivedprehospital IVF, and 16% (n = 191) didnot • Regardingprehospital IVF, the median volume of fluidgiven to the IVF group was 700 mL (IQR, 300-1,300) ED

9. Hampton DA et al. PROMMTT StudyGroup. J Trauma Acute Care Surg2013 • Prospective data from 10 Level 1 trauma centers • 1,245 trauma patients; 84% (n = 1,009) receivedprehospital IVF, and 16% (n = 191) didnot • Regardingprehospital IVF, the median volume of fluidgiven to the IVF group was 700 mL (IQR, 300-1,300)

10. Hampton DA et al. PROMMTT StudyGroup.J Trauma Acute Care Surg2013 • Prospective data from 10 Level 1 trauma centers • 1,245 trauma patients; 84% (n = 1,009) receivedprehospital IVF, and 16% (n = 191) didnot • Regardingprehospital IVF, the median volume of fluidgiven to the IVF group was 700 mL (IQR, 300-1,300)

11. LI T et al. Anesthesiology 2011 Effects of differenttargetMAPs (40, 50, 60, 70, 80, and 100 mmHg) on uncontrolledhemorrhagicshock Normotensive groups (80 and 100 mmHg) hadincreasedbloodloss (101%, 126% of total blood volume)

12. LI T et al. Anesthesiology 2011 A targetresuscitation pressure of 50-60 mmHgis the idealblood pressure for uncontrolledhemorrhagicshock. Ninety minutes of permissive hypotension is the tolerancelimit

13. Effect of norepinephrine during resuscitation of uncontrolled hemorrhagic shock in mice Blood lossat 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. Titration of initial fluid therapy to a lower than normal SBP during active hemorrhage did not affect mortality Dutton RP et al. , J. Trauma. 2002;52:1141-1146.

16. Spahn et al. Critical Care 2013 • Time elapsed between injury and • operation has to be minimized • 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)

17. Polytraumatisme - Hémodynamique Parasternale grand axe Doppler Oesophagien Parasternale petit axe Apicale quatre cavité et sous-xyphoïdienne Estimation du débitcardiaqueàpartir de la courbe de pressionartérielle

18. 53 patients admitted to trauma critical care units • The FREE wasperformed by an ultrasonographer or an intensivist and interpreted by an intensivistusing a full service portable echo machine • The viewsobtainedare the parasternallong axis (PLA), parasternal short axis (SA), and apical four-chamber and subxiphoid (SX) windows Parasternallong axis window Ferrada P et al. J Trauma. 2011 Parasternalshort axis window Subxiphoidwindow Apical four-chamberwindow

19. Ferrada P et al. J Trauma. 2011

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

21. 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 « Change startswith one person standing up and saying « no more » »