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SCCM Pod-502: Current Concepts: Hemostatic Resuscitation for Traumatic and Nontraumatic Hemorrhage

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This is the second episode of SCCM’s Current Concepts Series, in which authors unveil exclusive insights into the 2024 Current Concepts Course. Diane C. McLaughlin, DNP, AGACNP-BC, CCRN, FCCM, is joined by Nasim Motayar, MD, to discuss updates in hemostatic resuscitation for traumatic and nontraumatic hemorrhage. Dr. Motayar offers a concise overview of this Current Concepts chapter, providing valuable takeaways for healthcare professionals looking to enhance their clinical practice.

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This educational activity is supported by the SCCM Current Concepts Committee.

Dr. McLaughlin: Hello, and welcome to the Society of Critical Care Medicine Podcast. I’m your host, Diane McLaughlin. Today, we’re joined by Nasim Motayar in the second episode of our multipart series introducing the Current Concepts course and text available at the 2024 Critical Care Congress. Get ready to dive into each chapter as we chat with the authors, providing an exclusive sneak peek into their expertise in the course content.

Dr. Motayar is an assistant professor of clinical medicine and director of telecritical care medicine in the School of Medicine at Louisiana State University Health Science Center in Shreveport, Louisiana. Welcome, Dr. Motayar. Before we start, do you have any disclosures to report?

Dr. Motayar: Thank you so much and, no, I don’t have any disclosures.

Dr. McLaughlin: Thanks for joining us. It’s been great being involved with Current Concepts and talking to all the authors and hearing what’s new in critical care. With that in mind, do you want to introduce what your chapter topic is and what makes it a current concept in critical care?

Dr. Motayar: Absolutely. Thanks, Diane. The title of our chapter is Hemostatic Resuscitation for Traumatic and Nontraumatic Hemorrhage. This truly is an important topic. We are in the year 2023, approaching 2024, and I strongly believe that no one should be dying of bleeding. Well, actually, let me rephrase myself; that might be a strong statement. Anyone who makes it to a healthcare facility in a timely fashion should have a chance at survival, yet dying from bleeding remains one of the most common causes of death, especially in the young. Eighty-six million years of life were lost globally due to bleeding.

I believe that we as a community can do better than that. That’s why management of the bleeding patient is important and a core critical care concept that should be second nature to any practitioner working in any ICU, not just the trauma ICU. Whether you work at a level 1 trauma center or a small rural hospital, everyone should know how to approach and resuscitate a bleeding patient because bleeding can truly happen anywhere and really any time. It can happen before hospital admission or during. It can happen as a result of trauma, an unexpected fall, procedures, ulcers, and vascular issues, so It’s really not just a trauma problem. In fact, the COVID-19 pandemic is a great example of why we all need to have the basic skills to resuscitate these patients.

With the surge in capacity issues, we saw the impact of receiving delayed care or being unable to transfer to a higher-level center in a timely fashion, hence really highlighting the importance of all those working in any ICU needing to have the basic skills to stabilize these patients. If not treated, hemorrhagic shock leads to death. If not reversed quickly and adequately, it can lead to hypoperfusion and multisystem organ failure. If evidence-based resuscitation practices are not utilized, resuscitation can actually have its own complications and lead to more coagulopathy and bleeding.

That’s why it’s important for anyone working in any ICU to know the basic principles of managing these patients. Almost two million deaths globally are a result of bleeding. It truly takes a multidisciplinary approach to resuscitate these patients. Our chapter really emphasizes that prompt recognition, evaluation, and appropriate resuscitation can save lives. That is why we wrote this chapter, to share our expertise and experience of two level 1 trauma centers, to make sure everyone reading our book chapter or listening or coming to the course will have the basic skills and tools that they need to really adequately resuscitate these patients.

Dr. McLaughlin: I think, for a lot of people, when they think about somebody in hemorrhagic shock, they think, if it’s surgical, it’s surgical and, otherwise, it’s medical management with transfusions. But it’s obviously a lot more complicated. For those who aren’t too familiar with hemostatic resuscitation, could you explain the concept and how it differs from the traditional approach to managing hemorrhage?

Dr. Motayar: Yes, of course. Hemostatic resuscitation really just refers to restoring physiologic homeostasis. The goal in treatment of hemorrhagic shock is always to restore plasma blood volume and perfusion to end-organs and also to achieve hemostasis or gain control of the bleed through intervention, whether it be surgical or interventional radiology or other means, but also to focus on reversing coagulopathy and using the principles of damage control resuscitation, which focus on avoiding the lethal triad or diamond of trauma.

For those who are not familiar with those concepts, it basically refers to avoiding and reversing coagulopathy by, 1, cautious use of IV fluids. We know that If we give too much fluid, it can cause a dilutional coagulopathy. Specifically, if we use normal saline, it can actually lead to acidosis, which will worsen coagulopathy. This actually brings me to my next point, which is the importance of monitoring the base deficit and avoiding acidosis. We know that catecholamines and coagulation factors don’t work as well when the pH is low or in an acidic environment, so you definitely want to avoid that.

Avoiding hypothermia is another concept or priority, which, at really low temperatures, we know that both platelets and our coagulation system don’t function as well. Lastly, avoiding hypocalcemia, because calcium plays a role in the coagulation cascade. The idea is to resuscitate in a balanced and physiologic way, paying attention to the vicious cycle of hypothermia, acidosis, hypocalcemia, and coagulopathy.

Dr. McLaughlin: Now, you mentioned, even though it’s common in trauma, that there are also nontraumatic causes of hemorrhage. Does your approach to hemostatic resuscitation differ in these two groups?

Dr. Motayar: I think that’s a very interesting question, and there is a lot more data and research in the trauma population, not as much in the medical population. A lot of energy has been spent in understanding the pathophysiology of hemorrhagic shock from trauma at the cellular level and focusing on resuscitative strategies to address these pathophysiologic processes. The same information in medical patients is unfortunately lacking and is an area of much needed future research. However, the idea of the vicious cycle of bleeding, which includes acidosis, hypothermia, hypocalcemia, and coagulopathy, in my opinion, exists in all patients with hemorrhagic shock.

Organ hypoperfusion and hypoxemia lead to anaerobic metabolism, which then results in lactate production and worsening of acidosis. Biologically speaking, we know that our clotting mechanisms don’t work in conditions of low pH despite the mechanism of bleeding. Hypothermia can happen with resuscitation of colder fluids. Blood products in general are stored at a lower temperature. Large volumes of room-temperature or colder fluids will naturally drop the patient’s core body temperature and, again, we know that platelets and clotting factors don’t work as well when the temperature is low.

With hypocalcemia, calcium is a cofactor in the clotting cascade. We know that packed red blood cells have citrate in them, which binds calcium and causes hypocalcemia. These are principles, in my opinion, that are physiologic and apply to both traumatic and nontraumatic hemorrhage. But, obviously, I should also note that we are talking about massive hemorrhage, not a minor bleed.

Dr. McLaughlin: It sounds like this is almost a self-perpetuating cycle that occurs regardless of the actual cause of hemorrhage and, if prompt supportive care isn’t enacted, that it almost spirals out of control. That sounds like something everybody should read or attend and learn about. But what are the main challenges faced by healthcare professionals in enacting appropriate resuscitation or supportive care techniques?

Dr. Motayar: I think the main challenge right now is shortage of blood products nationally. Especially during the pandemic, we saw a reduction in the number of blood drives and donations, which really drained the supply. So supply and demand can definitely be an issue, especially if you’re not at a regional trauma center. This is more of a public health issue that needs to be addressed regionally and nationally, and obviously all of us clinicians need to do our part to make sure we’re reducing the number of blood draws and we’re practicing evidence-based medicine in terms of transfusing our patients who are more stable.

In terms of other issues, unfortunately, obtaining prompt access at centers that are less experienced can be an issue. Lack of knowledge in the optimal type of access can result in delays in resuscitation, specifically talking about flow rates and speed. Diagnosis in those with nonvisible bleeding can also be challenging. Hemorrhagic shock is a type of hypovolemic shock and needs to be differentiated from septic and cardiogenic shock, so less experienced clinicians may have a hard time with this.

Some of these challenges are modifiable at the clinician level; our book chapter really aims to address these issues. We have put together a chapter that we truly feel will give anyone working in any ICU the skills that they need to deliver prompt and adequate care and overcome some of these common challenges.

Dr. McLaughlin: I’ve actually seen more blood product shortages in the last year than I have in the last 20 years, and I never linked it with COVID or any of the blood drives, where we’ll have one unit of platelets for the whole hospital in a patient, I work in neurocritical care, who comes in with a life-threatening hemorrhage. I also am an NP by background, which means half my career was as a nurse and I was always taught that a 16-gauge IV is perfect for transfusions. It’s funny now, as an NP, I’m very quick to throw in a cordis, but if you were to give some advice to somebody who has a patient coming in who’s going to need massive transfusion, what would you recommend they get immediately to help provide transfusion?

Dr. Motayar: Diane, actually, I’m really glad you asked this question. My coauthor and I really worked hard at addressing some of these common concerns. We have a great table in our book that actually has different gauge IVs, central lines, RIC lines, introducer sheets, the actual size as well as flow rates, so how long it takes to give one liter of fluid through them. What we have done is we’ve put it all together in one table so anybody reading the chapter can just quickly look at it and see the differences. So if it’s okay, I’m going to refer you to that table; it’s table 2 in our book chapter.

Dr. McLaughlin: That’s awesome. I can’t wait to see it. I want to ask you to give some case studies. But since it segues a little bit better right now into how important the training and education in the field of hemostatic resuscitation for medical professionals, maybe we could do that one first and then come back and talk about some cases.

Dr. Motayar: I am an academic intensivist and an educator, so I may be biased, but it is very, very, very important. That’s why we’re here today. There is the Stop The Bleed Campaign nationally that focuses on training first responders and bystanders on measures to control bleeding in the field, but we also need to do our part and make sure that all of us working in the intensive care units are comfortable approaching these patients.

The first step is recognition of this condition. In our chapter and in the course, we thoroughly cover the steps involved in stabilization, again, through utilizing principles of damage control resuscitation, picking the optimal kind of IV access and really emphasizing a multidisciplinary team approach, localization of the source, and focusing on stopping the bleed, then also monitoring response. We talk in detail about anticoagulation reversal and actually provide a very handy chart that has all the information that you might need in one place that tells you how to approach patients who are on anticoagulation.

We also discuss utilization of more dynamic measures of hemostatic plug assessment. Specifically, we talk about the TEG. And lastly, we talk about de-resuscitation. All these steps are important in ensuring excellent outcomes. And I think through education, all of us together can try to make a difference in the bleeding patient population’s outcomes.

Dr. McLaughlin: I think anticoagulation reversal has been another hot topic and some of the medications utilized and what the preference is. So it sounds like another real high-yield table within the chapter that’ll be great to read. I also want to pitch that the Stop the Bleed campaign, at least for the last several Critical Care Congresses, has actually been there. So if you’re coming to Congress and you’re coming to the course, it might be an opportunity to check them out as well. That being said, do you want to share some case studies of patients that you’ve seen and how hemostatic resuscitation has been particularly effective?

Dr. Motayar: The data for hemostatic resuscitation really comes from casualties in war zones. World War I, World War II, the Cold War, the war in Iraq and Afghanistan, where they saw improved survivals if prompt surgery was provided, along with whole blood or higher ratios of blood and plasma. In 2013, there was the PROMMTT trial, which was a landmark study that was a prospective cohort study. They evaluated trauma patients who received blood products within six and 24 hours of presentation. What they found was that higher ratios resulted in significant reductions in mortality so they concluded that higher plasma/platelet ratios early on were associated with decreased mortality.

This was one study that really got everyone’s attention in terms of, Okay, maybe we do need more research in this area, which led to the PROPPR trial in 2015, which was again a much needed randomized control trial that evaluated the efficacy and safety of using the 1:1:1 ratio versus the 1:1:2 ratio. This was again in trauma patients, and they actually didn’t see a major 30-day mortality difference between the two groups. But what they saw was that the group that received the 1:1:1 ratio were more likely to achieve hemostasis in the first 24 hours and also were less likely to die of exsanguination. I think this was definitely an interesting study and one that has really influenced a lot of massive transfusion protocols across different institutions.

Dr. McLaughlin: That’s interesting too because that’s one of the hot topics in critical care, conservative versus liberal transfusion strategies and what hemoglobin goals or coagulopathy goals should be. So that sounds like something else that’ll be an interesting read. Is there anything in writing this chapter that surprised you or any new information that you learned?

Dr. Motayar: Honestly, the level of interest from the intensive care community and actually the medical and surgical community in learning more about how to approach these patients truly surprised me. In speaking with others, especially those from smaller centers, it was evident that some of the concepts that were second nature to all of us were foreign to others. They seem very excited to learn more about this topic, and the level of excitement is what really gave us the energy to write and teach about this topic.

It was also interesting to review different massive transfusion protocols from different institutions and appreciate the variation that exists, which further emphasizes the need for more research, especially when it comes to the medical population. This is a unique chapter in that we bring in both the perspective of hemostatic resuscitation in traumatic and nontraumatic hemorrhage, so looking at both patient populations.

What was truly special was the collaboration that it took to put this chapter together. For my coauthor and I to learn from each other and try to anticipate what our audience may need to have, like putting a table together that has anticoagulation reversal or the optimal type of access and the fluid rates through it or putting examples of just doing a regular FAST exam, that might not be something that is a skill that’s readily available to everybody who works in critical care, but we feel that it’s definitely a basic skill that would be nice to have in assessing these patients. Just trying to gauge the level of knowledge from our colleagues and just people we spoke to and how excited they were about learning these principles was definitely something that surprised me and very exciting to learn about.

Dr. McLaughlin: But just talking to you over the last 20 minutes, I’m super-excited to read the chapter and hear more from you at the course. To summarize, if there’s just one or two key points you want listeners to walk away with, other than to grab a copy of the book and attend the course if they really want to learn more about the topic, what would you leave them with?

Dr. Motayar: I would say that time to therapy really matters in hemorrhagic shock. We want to teach everyone how to optimize their patient outcomes. Our chapter teaches the reader the steps of recognition, immediate stabilization, resuscitation, hemorrhage control, the importance of being aware of and managing complications as well as de-resuscitation, which is a step that is often forgotten.

Principles of damage control resuscitation, which are well-known and accepted in the trauma community, but there is less experience in the medical community, even though we all seem to utilize the same principles in our bleeding patients, especially when it comes to utilizing massive transfusion protocols, which are often based on those principles. We’re really excited to share those concepts with our audience.

Again, I feel like there has been a lot of attention given to septic shock and time to therapy. We feel that hemorrhagic shock or really any type of shock carries the same weight and are very excited to bring more recognition and focus on how important it is to take a multidisciplinary approach, being aware of time to therapy and how important it is in reversing shock and managing these patients.

Dr. McLaughlin: It sounds like potentially decreased mortality in a patient population that there are areas that we can work on and improve.

Dr. Motayar: Yes, definitely. We truly believe that if we can do better on focusing time to therapy and reversal of shock will have improved outcomes. I’m hoping in the next couple of years, there is going to be more attention given to this area, especially in the medical population because, as we wrote this chapter, we saw that there was definitely more information in the trauma population, and the same level of information was lacking in the medical population. So hopefully, our chapter will also serve as a hypothesis-generating chapter for those who are interested in research to pursue more research in the medical population. We do believe that there is always room for improvement in managing any patient, but definitely patients with hemorrhagic shock.

Dr. McLaughlin: All right. Well, I can’t wait to hear more and see what continues to come out. But in the meantime, thank you so much for joining me. This will conclude another episode of the Society of Critical Care Medicine Podcast. For more on Current Concepts, please listen to the series and sign up for the 2024 Current Concepts precourse at Congress. And don’t forget if you’re listening on your favorite podcast app and you like what you hear, consider rating and leaving a review. For the Society of Critical Care Medicine Podcast, I’m Diane McLaughlin. Talk to you soon. Thank you.

Disclaimer: This educational activity is supported by the SCCM Current Concepts Committee.

Diane C. McLaughlin, DNP, AGACNP-BC, CCRN, FCCM, is a neurocritical care nurse practitioner at University of Florida Health Jacksonville. She is active within SCCM, serving on both the APP Resource and Ultrasound committees and is a social media ambassador for SCCM.

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Knowledge Area: Hematology