Dr' Biswadev Mitra

1
THE TRIAD OF DEATH
Dr. Biswadev Mitra MBBS, MHSM, FACEM
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The Triad of Death
Kashuk JL, Moore EE, Millikan JS, et al. Major
abdominal vascular trauma, a unified approach. J
Trauma 1982 22 672-679.
Moore EE. Laparotomy for the hypothermia,
acidosis and coagulopathy syndrome. Am J Surg
1996 172405-410
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Cases by Presentation
As at 20th May 09 Total Cases 2792
14
4
Trauma Cases
As at 20th May 09 Total Trauma Cases 382
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ISS
6
Trauma Cases by pH
pH
7
Trauma Cases by Temperature
?C
8
pH and Temperature
?C
pH
9
pH, Temperature and Coagulopathy

42


61

27
66
22
67
79
71
100
67
?C
pH
10
Triad of Death
Total Trauma Cases 382
45
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Blood Products Before rFVIIa Dose
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Triad Patient Response to rFVIIa
Note 8 out of 45 triad cases with an unknown
response to bleeding following dose 1
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Mortality of Triad Patients
Total Triad Cases 45
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Mortality vs. Response to rFVIIa in Triad
Patients
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Why Did 33 of Triad Patients Survive??

• Survivors vs. Non-survivors
• No difference in
• ISS (p0.4822) or Mechanism of trauma (p0.2137)
• Age (p0.6472)
• Hb (p0.6439), INR prior to dose (P0.5509)
• Platelet count (p0.8535), Fibrinogen (p0.8957),
• Blood products received prior to dose
• FFP (p0.2879), Platelets (p0.3759), Cryo
  (p0.6061)
• Size (p0.2108) or number of doses (p0.3198)

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Why Did 33 of Triad Patients Survive??

• Survivors vs. Non-survivors
• Significant difference in
• The number of units of RBCs (p0.0274)
• Gender (p0.0339)

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Blood products in Triad patients
survivors
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Conclusions

• Prediction of futility is difficult
• 33 of Triad patients survived
• Administration of rFVIIa should not be ruled out
  solely due to level of pH, temperature or
  coagulopathy
• Pre-rFVIIa PRBC volume have an association with
  increased mortality

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Acknowledgements

• Thanks to
• Local Investigators and Data Collectors at
  Participating Hospitals
• Dr Louise Phillips
• Dr Amanda Zatta

The Haemostasis Registry is funded by an
unrestricted Educational Grant from Novo Nordisk
Pharmaceuticals Pty Ltd