CICM SAQ 2015.2 Q16

a) Describe your strategies to control the bleeding in this patient. (70% marks)

Expedite surgery

Medical Measures to control bleeding

• Activate Massive Transfusion Protocol as per local hospital guidelines. Close liaison with surgeon
  and haematologist is warranted.
• Local pressure including adjunctive tourniquet use to control bleeding from the left leg wound.
• Target lower systolic blood pressure (e.g. 80 mmHg) until major bleeding has been stopped
  (absence of brain injury permits the same). Permissive hypotension is tolerated and has shown
  survival benefits in some studies.
• Correct hypothermia and acidosis.
• Packed cells transfusion to target haemoglobin concentration 70 – 90 g/L to achieve adequate
  tissue perfusion.
• Fresh Frozen Plasma to maintain INR & APTT < 1.5 x mean control. Usual dose 15 mL/kg.  Cryoprecipitate to maintain Fibrinogen levels > 1.5 g/L. Usual dose is 3-4 g or 50 mg/kg. (Fibrinogen
  concentrate is also allowed).
• Platelet transfusion to keep platelets > 50 x 109/L. With multiple injuries and suspicion of micro-
  vascular bleeding; platelet count can be aimed at > 100 x 109/L.
• Supplemental Calcium to maintain ionised calcium > 1.1 mmol/L
• Fluid Resuscitation with warmed crystalloid solutions. Aggressive fluid resuscitation is no longer
  recommended due to risk of pulmonary oedema, worsening of thrombocytopenia and coagulopathy
  due to haemoduilution.
• Use of ROTEM/TEG targets
• Tranexamic Acid (see below)
• Recombinant Factor VIIa: Not indicated at this stage (prior to surgery)

b) What evidence is there for the use of tranexamic acid in this setting? (30% marks)

Tranexamic Acid (TXA) is a synthetic lysine analogue that is a competitive inhibitor of plasminogen. TXA is distributed throughout all tissues with plasma half-life of 120 minutes.

Evidence:

• Recently published CRASH 2 trial; a multi-centre randomised, controlled trial examined the role of TXA against placebo in trauma patients, with, or at risk of significant haemorrhage. In more than 20,000 patients; TXA demonstrated a significant reduction in all-cause mortality at 4 weeks after injury (14.5% vs. 16%; RR = 0.91, P = 0.0035) and risk of death from bleeding (4.9% vs. 5.7%; RR=0.85, p=0.00077).
• The risk of precipitated thrombosis with the use of the lysine analogues has been of major theoretical concern; however, CRASH-2 showed that the rate of thrombosis, especially myocardial infarction, was lower with the use of TXA. No adverse events were described with the use of TXA in CRASH-2, although an increased rate of seizures has been described in patients receiving a high dose of TXA when undergoing cardiac surgery.
• A further analysis of CRASH-2 data showed that early treatment (< 1 hour and 1-3 hour from injury) significantly reduced the death rate of bleeding but treatment administered after 3 hours; increased the risk of death due to bleeding. Hence, TXA should be administered within 3 hours of injury.
• TXA should be considered as adjunctive therapy in patients with traumatic haemorrhage in the setting of overall patient management; including strict attention to the control of bleeding, physiological and metabolic parameters, coagulation and temperature maintenance.