L’hémorragie du polytraumatisé

J. DuranteauHôpitaux universitaires Paris-Sud

Université Paris-Sud XI

B Vigué

Contrôle de l’hémorragieRestauration d’une

physiologie normale

Pré-hospitalier Bloc Réanimation

Mortalité précoce : choc hémorragique non controlé

Mortalité tardive : Défaillance d’organes

Choc hémorragique traumatique

Déchocage

Contrôle de l’hémorragieRestauration d’une

physiologie normale

Pré-hospitalier Bloc Réanimation

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”

Afin de limiter la dilution des facteurs de la coagulation: Limiter le remplissage vasculaire

Tolérer un certain degré d’hypotension artérielle

Contrôle rapide du saignementStratégie de « Damage Control »

Débuter précocément la transfusion de produits sanguins

Before arrival at the hospitalRinger’s lactate (ml)

Trauma centerRinger’s lactate (ml)Packed red cells (ml)

Survival to discharge Length of hospital stay

Immediate resuscitation

(n = 309)

870 ± 667

1608 ± 1201133 ± 393

193 (62%)14 ± 24

Delayed resuscitation

(n = 289)

92 ± 309

283 ± 72211 ± 88

203 (70%)11 ± 19

P value

<0.001

<0.001<0.001

0.040.006

Bickell, WH et al. NEJM 1994

Patient care times (min)Transport intervalTrauma-center interval

Scene SAP (mmHg)

Trauma-center SAP (mmHg)Hb (g/dl)Prothrombin time (sec)Arterial pH

Immediate resuscitation

(n = 309)

13 ± 644 ± 65

58 ± 35

79 ± 4611 ± 3

14 ± 167.29 ± 0.17

Delayed resuscitation

(n = 289)

12 ± 652 ± 99

59 ± 34

72 ± 4313 ± 211 ± 2

7.28 ± 0.15

P value

0.02<0.001<0.001

0.42

Bickell, WH et al. NEJM 1994

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

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)

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)

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)

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 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

Effect of norepinephrine during resuscitationof uncontrolled hemorrhagic shock in mice

Blood loss at T90 (µL)

Harrois et al. ESICM 2012

Effect of norepinephrine during resuscitationof uncontrolled hemorrhagic shock in mice

Villous perfused density in each group (% ± SEM)

Harrois et al. ESICM 2012

Dutton RP et al. , J. Trauma. 2002;52:1141-1146.

Titration of initial fluid therapy to a lower than normal SBP duringactive hemorrhage did not affect mortality

Spahn et al. Critical Care 2013

Time elapsed between injury and operation has to be minimized

Concept of low volume fluid resuscitationPermissive 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)

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. 2011

53 patients admitted to trauma critical care unitsThe FREE was performed by an ultrasonographer or an intensivist and interpreted by an

intensivist using a full service portable echo machineThe 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 grave80 ≤ PAS ≤ 90 mmHg

Présence de TC grave (GCS ≤8) PAS ≥ 120 mmHg

Echec de maintien de la PAS

Administration précoce vasopresseurNoradrénaline Débuter à 0.1 g/kg/min

Titration du remplissage vasculaire Indices de précharge dépendance (ΔPP, ΔIVC, ΔITV)

Débit cardiaque Lactate

Priorité : Arrêter le saignement

Contrôle du saignement chirurgical et/ou embolisation

Evaluation de la fonction ventriculaireAppréciation visuelle de la FEVG et du VD

C. LaplaceC. Ract

P.E. LeblancG. CheissonA. Harrois

S. FigueiredoS. HamadaS. TanakaB. Vigué

J. Duranteau

Service d’Anesthésie-RéanimationHôpitaux universitaires Paris-Sud

Université Paris-Sud XI

« Change starts with one person standing up and saying « no more » »