Thank you so much. My name is Nassim Motayar. I'm an assistant professor of critical care medicine at Louisiana State University Health Science Center in Shreveport, and I'm going to talk about hemostatic resuscitation of traumatic and non-traumatic patients. I feel very passionate about this topic. I feel like we're in the year 2024 and any patient that makes it to the hospital, any bleeding patient that makes it to the hospital, in a timely fashion should truly have a chance at survival. So why was that going? Can you go back? One more. And so what we've done is Dr. Morali and I have put together a chapter that brings the expertise of two different level one trauma centers and also two different backgrounds to try to provide you with the skills that you need to try to save these patients. I have no disclosures or conflicts of interest, and my goal today is for anybody in this audience to get a really good idea of what the pathophysiology of hemorrhagic shock is, and also to know the steps needed to, one, recognize it and to manage these patients, and also to be aware of all the tools that are available to you to try to save these patients. So to talk about hemorrhagic shock, first we want to talk about what it is, why it's important, and how important is it. So I'm going to start by giving you a definition. Hemorrhagic shock is a state of hypovolemia resulting from acute blood loss that leads to poor tissue perfusion, impaired oxygen delivery, and organ failure, and if not treated, death. And why is it important? Well, it's causing both an organ failure, which we know carries a high mortality, but also death. And if you look over here, the causes of hemorrhagic shock generally are from the trauma population, but we also see it in the medical ICUs and in our medical population, too. So the second most common cause is AAA aneurysms. You can see it with peptic ulcer disease and maternal hemorrhage. And then why is it so important, and how important is it? If you look on the right side, you can see that there is 2 million deaths, or close to 2 million deaths, globally related to hemorrhagic shock, and that translates to 85 million years of life lost. So it carries a lot of morbidity and mortality. It's not all bad news, though. There is some good news, and the good news is that it is time-sensitive, so it's a time-sensitive process, and if you catch it early, and if you act appropriately and quickly, you can actually save these patients, and that's why we're here today. So your goal is going to be to first restore the plasma blood volume. You want to reverse coagulopathy and try to mitigate... Is this going? Okay, and mitigate any coagulopathy that happens, and resuscitate in a balanced way so that you don't cause any coagulopathy as you're resuscitating, and we'll talk a little bit more about that as we go on. And obviously, you want to identify and stop the source of bleeding. So just a quick review of pathophysiology. Mean arterial pressure map is a product of cardiac output and resistance, and cardiac output is a product of heart rate and stroke volume. And so what happens in hemorrhagic shock is you have blood loss, so your stroke volume is down. As a result, your sympathetic nervous system gets activated, and you get release of catecholamines. That results in an increase in your heart rate and also vasoconstriction or an increase in your systemic vascular resistance, and it's doing that to try to maintain your map to keep your organs and the rest of your body perfused. Unfortunately, in the case of severe hemorrhagic shock, you've lost so much blood that your stroke volume is down. So despite having these mechanisms to try to compensate, you fail, and your map drops, and you end up with impaired oxygen delivery, tissue hypoperfusion, and organ failure, and if not, reverse death. If you look at the bottom, hemorrhagic shock is a type of hypovolemic shock, and so you expect your CVP to be low, your cardiac output we talked about, it's going to be low, and your systemic vascular resistance is going to be high, and your venous oxygen saturation is going to be low. So how can you estimate the probability of survival? This depends on various factors. The first one is the type of anatomic injury, so the type and severity. So if I have a hole in my left ventricle, that's probably going to be morbid, but if I have a really bad laceration to my leg, that's probably something that we can save. Next is physiologic injury, so talking about basically what happens at the tissue and the molecular level. So in the case of hemorrhagic shock, we talked about hypoperfusion, vasoconstriction, and oxygen debt. So what happens is your organs start to get damaged, specifically your liver, your intestines, your kidneys, and you end up with multisystem organ failure. So your goal is try to reverse blood flow as soon as you can to try to save as many organs as you can. In the case of oxygen debt, also at the molecular level, your mitochondria, which are in charge of aerobic metabolism and producing ATP, they're going to convert to anaerobic metabolism, and you're going to end up with lactate production, which leads to acidosis, and it gets us back to the lethal triad of trauma and worsens coagulopathy, which we'll talk about in a little bit. Next is patient reserve. So that's the patient that's coming to your ICU, so their age. We already heard that older patients are more vulnerable. They don't have the same compensatory mechanisms. They might have heart failure, they might be on antihypertensive medications, beta blockers, so they might just not be able to mount the same kind of response. And then a younger patient is going to have more reserve and have more ability to compensate. And then the last thing is error or operator experience, and this is where all of us come into play. If you don't recognize hemorrhagic shock, you're not going to be able to reverse it. Delaying time to therapy in these patients leads to more end organ damage and death, so you really want to be aware of how to manage or how to approach and recognize hemorrhagic shock to be able to reverse it. And then also proceduralist experience, so it would depend on that as well. So all of these together, some of which are modifiable, and those are the ones that we're going to talk about today, and some are not, are going to determine your patient's outcome. So just a quick overview of management of hemorrhagic shock. First, you want to be able to recognize it. Then you want to work on stabilizing it, and you already heard that it's a very multidisciplinary approach to stabilizing these patients. Then you want to localize and stop the bleeding, and then you want to monitor for response and look out for any complications, but don't forget de-resuscitation. That's just as important as resuscitation, and we'll talk a little bit about that later on. So this graph is probably familiar to everybody. I'm sure you've seen it at some point in your career, but I feel like it does apply to almost any critical care illness that I talk about. So you have therapy here on the y-axis, and then you have time on the x-axis. So if you look here, in the initial stage, you have resuscitation, and that's early on, where you're bleeding patient with hemorrhagic shock is coming in, and you're trying to resuscitate them with blood products. You're getting access. You're trying to give them the volume back to try to prevent hypoperfusion and organ damage. Then it's optimization. Maybe your patient has stabilized a little bit, and you have some more time, and the speaker previous to me talked a lot about that. So you want to really make sure you're trying to identify and fix the source of bleeding. Stabilization is when they're getting better. Maybe you're just now watching them. If you haven't gone in definite control because the patient was still unstable, this is the time to do that now. And then as the patient gets better, and they're moving into the recovery phase, you really want to focus on de-resuscitation, and so what is de-resuscitation? Basically, that's referring to any complications that they may have from resuscitation. So if they have volume overload, now you want to focus on diuresing them. If they've just been in the ICU for too long, and they're weak, you want to make sure you get physical therapy on board. If you have started any medications in the ICU that don't necessarily need to be continued, then you want to come up with a plan to start weaning those things off. So it's very important. So next we talk about evaluation and management, and the first step is recognition. So what you want to do is you want to do a good history and a physical exam. Unfortunately, with a lot of our ICU patients, you can't really get a history, but that history that you get from whoever was present on scene, so they can tell you about the amount of blood loss or the surrounding information from the environment might actually be very helpful to you. So don't forget to ask those questions. And then the table down here is the forward stage classification system from ATLS, and I'm sure everyone's seen this at some point in their career, but probably not using it so much now in your clinical practice. I'm going to skip over my question, but the reason why it's fallen out of favor and its relevance has actually been called into question is because not all patients respond the same way, and the order can really vary. So what this classification system is trying to do is based on vital signs and organ perfusion, so your urinopause, encephalopathy, so your GCS score, and the base deficit. It's trying to give you an idea of how much blood a patient might have lost, and based on that, it's trying to give you guidance into what you should do. So for example, here everything is looking pretty normal. It's class one. They're estimating less than 15% blood loss and saying you should monitor. And then as you're starting to see more vital sign abnormalities, then they move forward to say, okay, prepare blood transfuse and activate massive transfusion protocol. But again, not all patients are the same. Pregnant patients were brought up earlier, and we know that physiologically their blood plasma volume is expanded at baseline. They might be tachypneic or breathe faster at baseline. Their heart rate is up. They're anemic, so a pregnant patient can actually lose up to two liters of blood before they start showing any symptoms, and by that time, it's going to be too late for you to save the mother or the baby. So you really want to take your patient factors into account and treat the patient that's in front of you and actually have a lower threshold of admitting and resuscitating younger patients that can actually compensate more. And then elderly patients, again, we talked about. So now let's go through a quick case. So you're on your ICU shift. The ER physician calls, and they say they have a 28-year-old female that is bleeding. They have resuscitated them. The patient was initially in hemorrhagic shock. So you walk down to the ER, and you look at the monitor. The heart rate is elevated at 110. She's a little hypoxic, satting 90% on two liters. Her respiratory rate is elevated at 30. Her blood pressure is on the lower side, 85 over 50, and her temperature is also low at 36.8. Then you go to examine the patient further. You look at their mucous membranes, and it looks very dry. You look at her capillary refill, and it's delayed. Then you go to listen to her lungs, and she's tachypneic, but she's got clear lung sounds. She's confused or encephalopathic. And then next, you really want to pay attention to looking at her skin and actually examining her. You're looking for any kind of bruising, because if you see bruising in a certain area, that might give you an idea of where the patient might be bleeding. You want to palpate for pain. Even though patients are encephalopathic, they often grimace if they have pain, so that can help you. And obviously, you don't want to miss any visible bleeding. So next, obviously, we can all utilize ultrasound. So one of the things that you can do is look at the IVC collapsibility index, and in her case, you would expect it to be increased. And then you can also look at the IVC diameter, which you would expect it to be small in the case of hemorrhagic shock. Stroke volume variation was also mentioned earlier. I don't have it on the slide, but that's another thing that you can look at. And then the eFAST exam is very helpful, and for those of you working in the medical ICU, this might not be something that you do daily, but it's actually pretty easy to learn, and it's a very good and useful tool to have. So if you look over here, it's looking at the right upper quadrant, and you have the liver here and the kidney, and this is in a normal patient. On this one, you can see that there's free fluid there, so that can help you to decide what your next step is. And then also, you can partially visualize the thorax and the diaphragm. So if you look at this one here, you see the diaphragm, and you see that there is blood above the diaphragm, so that points towards the thorax. And then here, you have the left upper quadrant view. Again, you have the spleen and the kidney, and here it's pointing to some free fluid there. Suprapubic, so you have the bladder here in a normal patient. And then if you look at the abnormal, you can see free fluid right above the bladder, so that goes towards a pelvic injury. And then you can do the subxiphoid view, which I'm pretty sure everybody here is familiar with how to get it, but you can see that this patient has a pericardial effusion. So, I'm not going to review this table, but basically, it's putting together everything that we just did for that patient to summarize the signs and symptoms that you're looking for when you're evaluating these patients with hemorrhagic shock. So, your primary goal in emergent stabilization of a patient with hemorrhagic shock is like any other critical care patient. So, you want to restore circulation, pay attention to airway and breathing. So, here, what becomes really important is getting good IV access. And by that, I mean large-bore IV access, and we'll talk about that in a little bit. Using IO access is becoming more favorable, especially on the field or in emergency situations. A lot of the times, these patients are very hypovolemic, so it's difficult to get intravenous access. So, in those cases, IO access might be helpful. We'll talk about some of the limitations of that in a little bit. But what you want to do is restore circulation as fast as you can. Next is airway, and you want to take a thoughtful approach to how you manage these patients' airways. Because they are extremely hypovolemic, RSI can actually put them into cardiac arrest. So, you really want to make sure that if you're going to try to drop their preload and give them positive pressure, that it is truly what they need in that moment. Because what you can do, if airway is not a priority because they are just encephalopathic and you're thinking about protecting their airway, is you can use a supraglottic airway and use bag mass ventilation and then resuscitate them, then get definitive airway after. So, this is a common scenario. Unfortunately, I don't have my polling set up, but this is a common scenario that all of us in this room have been presented with at some point where a bleeding patient needs more access and somebody calls you and says, hey, can you come through a femoral central line? And that is almost never the right answer. Here the answer was 14-gate standard IV. And when I have given this talk before, people are split between C and D. So, we have provided you in the book chapter with this really amazing table that goes through the different sizes of vascular access that's available to you and how quickly you can infuse a liter of fluids through it. And this is courtesy of the ETM course blog. And so, if you look, the 20-gauge IV, which almost every patient has, and sometimes there are places with less experience that try to resuscitate through that, it takes almost seven minutes to get a liter of fluids through that. And so, in patients that are truly in hemorrhagic shock, that are bleeding in front of you, you don't have seven minutes. So, you want to try to go something, you want to try to go with something closer to the top of this table, so an eight and a half wrench RIC line, which RIC lines aren't as available in non-trauma centers, but you can always find the sheath introducer or 14-gate standard IV. So, one thing that they haven't put on that table is IO access. And just thinking about normal anatomy, IO access is in the bone. And so, your bone has trabeculae, and that trabeculae can actually impede the flow rate. It's fine to use it, but if you're using it, then you want to somehow apply more pressure to try to get through that. And that's one thing that a lot of times people forget. So, we heard about using rapid transfuser devices. Those may not be available if you're not a trauma center, but if you do have them, they're very handy. They have a heating unit on top, so it allows you to warm up fluids or blood products that you're giving it, so you don't run into issues with hypothermia. But if you don't have, that's okay. You can just use a regular pressure bag. And if you don't have a regular pressure bag, you can just apply manual pressure. So, put your hand on that bag and squeeze it as fast as you can and as much as you can and try to get the blood products in. And so, to begin, a small amount of fluids can be used. Obviously, you don't want to use large amounts, and we'll talk about why in the next couple of slides. Okay, so hemodilution. If you're using too much fluids, you're going to cause hemodilution, and you're going to actually worsen coagulopathy. And obviously, in a bleeding patient, you don't want that. So, you want to limit the amount of IV fluids that you use. And you also want to make sure you take a balanced approach to resuscitation. And we heard about that earlier, and I'll try to emphasize that again in my next few slides. You also want to try to avoid hypothermia. Our trauma patients, a lot of the times, they'll have exposed organs, and they're losing their body heat through that. But in our medical patients, too, if you're not paying attention, one, they can come in hypothermic, but if you're not paying attention to how you're resuscitating, the blood products that you are giving are not going to be – they're going to be cold or room temperature, so ultimately, when you give them a large volume, you are going to drop their body temperature. And we know that your coags don't work as well when it's cold, so you really want to avoid hypothermia. Hypocalcemia, we know that calcium is a cofactor in the clotting system, and so you do not want hypocalcemia. Blood has citrate in it – can you go back? Blood has citrate in it, so when you give blood, it's going to bind the calcium, and it's going to result in hypocalcemia, so you really want to pay attention to that and make sure you're repleting your calcium appropriately. Acidosis, we also talked about oxygen debt, and then when you have – and then you get anaerobic metabolism, lactate production, and then you end up with acidosis, and your catecholamines don't work well in acidic conditions, so you really want to try to avoid that as well. All of these together can worsen bleeding or lead to bleeding. And so the lethal triad of trauma was hypothermia, acidosis, and coagulopathy. When you talk about the lethal diamond, that's just adding hypocalcemia to that mix. And it's talking about what you should avoid to try to resuscitate hemostatically and restore homeostasis. And so those are the ideas of damage control resuscitation. So when you talk about balanced resuscitation, most of the experience initially came from the battlefield. They saw that when they're using a balanced approach to giving blood products, the patients actually do better. And so we heard about the two landmark studies that were done to try to assess what might be the optimum ratio to use to resuscitate these patients. And I'm not going to go over it because you guys already heard about it, but the PROMPT study was a prospective randomized trial. And what they did was they looked at resuscitation practices, and what they saw was that there was actually a great deal of variation from intensivist to intensivist. And they saw that a higher ratio led to better outcomes. And so two years after this study, the next study, the PROPPER trial, which is what everybody was looking forward to because finally we had a randomized control trial that was going to try to give us the answer of what might be one unit of or one optimal unit for resuscitation. So they looked at the 1 to 1 to 1 and 1 to 1 to 2 ratio. And you already heard that even though it didn't decrease 30-day mortality, it did reduce the number of the mortality from exsanguination in the first 24 hours. So they actually achieved hemostasis faster. And this actually led to most trauma centers changing their massive transfusion protocols to make it 1 to 1 to 1. And so whole blood, whole blood is hard to get. If you're not at a trauma center, chances are you probably don't have access to it. I know that where I am, if you're in the trauma unit, it's reserved for you. But if you're in the MICU or somewhere else, you always have to get permission from the trauma team to use it. Sometimes you can get it because the shelf life is a little shorter and they don't want it to waste. So depending on how much traumas they have, you might be lucky to get some. So if you look at this versus component therapy, in 500 cc's, you're pretty much getting everything that you need. It's very physiologic and it's very balanced. So the hematocrit is 38% to 44%, platelets are 150% to 400%, coags are 100% functional, and you're getting 1 gram of fibrinogen. So if you think about if you were doing that as component therapy, you would be giving your patient a lot more volume than you would with whole blood. So the data shows that in trauma patients, low tidal whole blood reduces overall transfusions and increases survival. And in the medical population, unfortunately, the data is lacking. But I have used it for a patient or two that have really been actively having a GI bleed in front of me. So hopefully this is an area that will be investigated in the future. So we also heard about triggers for massive transfusions protocols. And it's very interesting. Looking at different institutions, the triggers can be very different. I think our trauma colleagues do have some guidance from the East Association. But when it comes to the medical patients, there's really no guidance. So a lot of the times, it's clinician judgment. So if you're going down to see a patient and they're unstable and they're bleeding out in front of you, then you really want to try to activate it. But the only other criteria that you see in almost all massive transfusion protocols that I have looked at is looking at the number of packed red blood cells that a patient needs and that duration of time. So if they're needing three or four in an hour, that probably automatically triggers the massive transfusion protocol. We also already heard about the ABC scoring system and the shock index. I'm not going to go over it. Remember that a type in screen takes about 15 to 30 minutes. So generally, when you have a patient in hemorrhagic shock, you're not going to have a type in screen, which brings me to my next point. So what happens when you activate a massive transfusion protocol is first you've identified that your patient needs it. And you really want to be sure that the patient needs it before you activate it, because once you do, they do end up wasting a lot of blood products. So make sure you're using it for the right patient. So you identify and activate, and that usually takes direct communication with your lab or however your system is set up. And then what happens after that is they start to prepare and deliver coolers and coolers and coolers of blood products. And what they do is they make sure that this happens in a timely fashion so your patient gets what they need. And then we don't have a type in screen. So generally, what happens is in females of childbearing age, they're going to use O negative blood. And in everybody else, if they have O negative, they will use it. If not, they can just use O positive and AB plasma. Keep in mind that if you had a patient that you resuscitated and stabilized and they were a type A or there was some kind of a mismatch because you didn't match them and you gave them seven to nine units of blood, then you pretty much replaced their whole blood volume. So you don't want to go back to type A in the next hour or the next day. You want to give them some time. And we already talked about the lethal diamond of trauma, but because it was a question I'm going to mention again. So it's acidosis, hypothermia, coagulopathy, and hypocalcemia. Optimal blood pressure is another point of conversation that comes up. I think there is more data, again, in the trauma population. And the idea here is that if you're using a lower systolic blood pressure, and that can range from 70 to 100, I feel like most places do try to go for 85 to 100, though. Maybe not as low as 70, but the idea is lower pressure allows your clot to stabilize. And if you increase that pressure, it's going to dislodge the clot and it's going to worsen bleeding. So that's the idea behind trying to do a lower blood pressure. The benefit is less clear in the non-trauma elderly patients. I like to think of them as having a little bit of homeostenosis. They might have hypertension. They might have higher blood pressure at baseline and autoregulate higher. So the question becomes, how low can you go? And so what you're trying to do is try to look at the benefit of potentially stabilizing the clot and the risk of getting multisystem organ failure. So the data in the medical population isn't as clear. And I think what you should do is try to customize your approach to the patient that's in front of you. So if my baseline blood pressure is 90, I don't want you to bring it up to 120 when I'm in your trauma bay and you're trying to resuscitate me. So major sources of bleeding, we already talked about how to recognize it, so I'm not going to go over that. But blood on the floor, you always want to pay attention to that. If you see three liters of blood on the floor or a liter, that will help guide your resuscitation, that initial resuscitation. But when you think about other sources of hemorrhagic shock, you have blood on the floor and four more. So you have the abdomen, pelvis, peritoneum, long bones, and the thorax. So sources of bleeding, you can refer to our chapter for this. And it was already mentioned before, so I'm not going to go into it. We also actually heard about coagulopathy that happens during trauma. And so I'm not going to go over that either. In terms of guiding your resuscitation, we can use the conventional studies such as PTINR. It's not as good. It takes longer, and it's just giving you a static measure. And we also heard about the TAG, which is more of a dynamic measure, and it has a really quick turnaround. It gives you more information about the patient's ability to clot. So because we're running out of time, I'm not going to go into this in detail. But it is provided in our chapter, so you can review it there. And then we also put together a table to kind of put useful information that might be helpful to you. So when you talk about coagulopathy, you have coagulopathy that can happen as a result of trauma. But you can also have patients that are on anticoagulation. So you want to make sure you know how to reverse them quickly. And so we have put this together to try to help you. And then when it comes to platelets, the data is limited. So when to transfuse, and it's guided by clinician experience. If somebody has CNS issues or active bleeding and needs major surgery, you want to aim to be greater than 100,000. Active bleeding, you want to aim to be greater than 50. And what you can do is you can use aminocaproic acid, TXA, desmopressant. And obviously, the gold standard is platelet transfusion, but it's hard to get platelets these days. So TXA was also brought up. And I think that's another important one to just really quickly mention. The major trials that have looked at TXA and hemorrhagic shock are the CRASH-2 trial, which looked at giving TXA within three hours of injury in trauma patient and saw a reduction in mortality. So our trauma colleagues do use TXA. Halted trial was for GI patients, and they did not see a difference in mortality. And they actually did see a signal for increased VTE. So there was really no benefit in using it. Women trial looked at TXA in OB patients, postpartum hemorrhage. And what they saw was that there was a mortality benefit. So you are more likely to see TXA being used in OB patients. And then traumatic hemorrhage was talked about. The Stop the Bleed campaign is a big campaign that's going on, trying to give every bystander the skills that they need to stop bleeding. So I'm not going to go over that. And again, it was mentioned. Non-traumatic hemorrhage, we have listed the causes. It's also in our textbook. So you can refer to that. And then just getting to my last point is complications and de-resuscitation. So we already talked about what happens when your patient's stabilized and recovering. Now you're really trying to approach more from replacing what you're seeing being lost to taking a more restrictive transfusion strategy with hemoglobin of 7 and hematocrit of 21 as your goal. Manage any complications. So sometimes we see trialing or tackling these patients. And you just want to provide them with supportive care and then optimize their volume status as they're improving. And you can see electrolyte imbalances. So as you're resuscitating, you want to be watching out for those and fixing anything that comes up. And then optimum balance, if you're staying too restrictive, so if you're not giving enough, you're going to have hyperperfusion, ischemia, and organ damage. If you're too liberal, then you're going to end up with potentially dislodging the clot, so more bleeding. You can get edema. You can get compartment syndrome. So the idea is to try to be in the middle where you're just replacing what the patient is losing. And then once they're stabilized, you are following more of a guided resuscitation strategy that's restrictive. And so take-home point, bleeding is a big problem. When we talk about sepsis, everybody knows about not using hypotonic or hypertonic fluids. We all talk about using balanced fluids. It's the same idea here. The idea is when you're resuscitating them, you want to do it in a balanced way. And for now, the best data that we have says in the trauma population, obviously whole blood, but if you can't, then try to make sure you stay with a one-to-one-to-one ratio. Rapid identification is really important. If you don't know what's happening, you're not going to be able to treat it. And I gave you some idea of how to approach these patients and what tools are available to you. And then lastly, please don't forget to de-resuscitate as these patients are getting better. And that's all I have. Thank you.

hemostatic resuscitation

traumatic patients

non-traumatic patients

hemorrhagic shock

acute blood loss

massive transfusion protocols

coagulopathy management