Control of bleeding in major trauma

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Control of bleeding in major trauma

• LARS BORRIS, M.D.
• DEPT. OF ORTHOPEDICS
• AARHUS UNIVERSITY HOSPITAL
• AARHUS
• DENMARK

2
Typical lesions responsible for bleeding after
major trauma

• Blunt aortic injury
• Blunt hepatic injury
• Blunt splenic injury
• Head trauma with bleeding
• Pelvic fracture with active bleeding

Patients with these injuries should not receive
anticoagulants until they are hemodynamically
stabilized either operatively or non-operatively
by angiographic embolization (coiling) or
otherwise
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Blunt aortic injury
4
Surgical treatment treatment with graft
Neschis DG, Scalea TM, Flinn WR, Griffith BP.
Blunt aortic injury. N Engl J Med 2008 359
1708-16
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Blunt hepatic injury (grade IV)
Angiography
Coiling procedure
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Blunt splenic injury with ongoing bleeding
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CT scan of pelvic fracture with ongoing bleeding
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Damage control with packing should be initiated
already in the emmergency room
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CONCLUSION

• Risk assessment alone is not reliable to select
  patients for thromboprophylaxis
• LMWH is the drug of choice for prevention of VTE
  after trauma
• Ongoing bleeding due to organ injury or pelvic or
  extremity fractures are contraindications for
  LMWH after trauma
• Selection of trauma patients for VTE prophylaxis
  to avoid bleeding complications needs evaluation

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All younger surgeons responsible for care of
major trauma cases learn how to perform pelvic
packing on human corpses
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The pelvic packing precedure is seen as a routine
intervention which increases its use and has
significantly reduced the time spent after the
patients arrival in the emergency room
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Arteriographic coiling as supplementary treatment
of severe bleeding
1. A catheter is inserted in the right femoral
artery 2. Coils 3. The arteral lesion
13
Hougaard K, Vester AE, Holme JB, Nielsen DT,
Christensen EF. Initial treatment of patients
with unstable pelvic fractures and severe
bleeding. UFL 2003 165 4291-4.
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Conclusion

• Angiographic embolization was life saving in 4
  out of 8 patients
• Pelvic packing was life saving in 1 patient

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Treatment strategy
Pevic fracture with bleeding
FAST-US
Intra-abdominal fluid
Intra-abdominal fluid
Hemodynamicly unstable
Hemodynamicly stable
Packing
Arteriography with coiling
Conservative treatment
Laparotomy
FAST focussed assessment by sonography
Hougaard K, Vester AE, Holme JB, Nielsen DT,
Christensen EF. Initial treatment of patients
with unstable pelvic fractures and severe
bleeding. UFL 2003 165 4291-4.
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Thank you very much