ManagemenManagementransfusiontransfusion

Dr. Dr. RobRobProfessor, DaProfessor, Da

Critical CCritical CEmergenEmergenTrauma Trauma

t of massive t of massive n in trauman in trauma

bert Greenbert Greenlhousie Universitylhousie University

Care MedicineCare Medicinency Medicinency MedicineNova ScotiaNova Scotia

ObjecObjecObjecObjec

Briefly review the controversyBriefly review the controversysupporting literature for masstransfusion

Using a case, introduce the mg ,transfusion protocol at CDHA

Highlight key management strin trauma patients requiring mtransfusion

ctives:ctives:ctives:ctives:

y andy and ive

assive

rategies massive

Breaking BlBreaking Bl

Bl di l d t d ti i l d l

Breaking BlBreaking Bl

Bleeding leads to a reduction in preload, lhypotension, and global tissue hypoxia

Hemorrhage is the second most frequent g qbrain injury and accounts for 30-40% of tr

Autopsy review of combat trauma revealswere treatable if not for exanguination2were treatable if not for exanguination

Sauaia A, Moore FA, Moore EE, et al. Epidemiology of trauma deaths: a reassessmHolcomb JB caruso J McMullin NR et al. Causes of Death in Special Operations FSurg. 2007;245;986-991

leeding Badleeding Bad

l di t t

leeding Badleeding Bad

low cardiac output,

cause of death after raumatic fatalities1

s that 15-20% of deaths

ment JTauma.1995;38:185-93Forces on the Modern BattlefieldL2001-2006. Ann

The “LethThe “LethThe LethThe Leth

Coagulopathy, hypothermia and acidosis are well known markersknown markers mortality after traumatic

1hemorrhage1

1. Ferrara A, MacArthur JD, Wright HK, et al. Hypothermia and acidosis worsen coagulopathy in the patient requiring massive transfusion. Am J Surg. 1990;160:515–518.

hal Triad”hal Triad”hal Triadhal Triad

Epidemiology of mEpidemiology of mEpidemiology of mEpidemiology of m

Traditional resuscitation with crystalloids cause a dilutionalycoagulopathy

In trauma, need for MT is 3-5%in military trauma)● but 30-60% mortality

massive transfusionmassive transfusionmassive transfusionmassive transfusion

% (10%

What we usWhat we usWhat we usWhat we us

You lose blood…we give you sYou lose blood…we give you swater…???

Crystalloid resuscitation+++“Prove” that the patient doesnProve that the patient doesnblood● Blood as a last resort● Little to no use of platelets and p

sed to do…sed to do…sed to do…sed to do…

saltsalt

n’t needn t need

plasma

New paradigm: replaNew paradigm: replaNew paradigm: replaNew paradigm: repla

You lose blood…we give you bYou lose blood…we give you b

Also you lose other “things”Also, you lose other things● Platelets● Coagulation factorsg

After we determined that bloodproducts are good in trauma…● we looked at systems…● massive transfusion protocols

ace what you lose...ace what you lose...ace what you lose...ace what you lose...

bloodblood

d …

Don’t bore me wDon’t bore me wGive me tGive me t

with evidence….with evidence….the best.the best.

Prospective cohort study10 level-1 US trauma centersEvaluated the association of ton mortality● Ratio of platelets/plasma to RBC

Primary outcome: in-hospital m

he early use of blood productsy p

Cmortality

ResResResRes

Overall 1245 ptsOverall 1245 pts

ultsultsultsults

Blood and the othBlood and the othBlood and the othBlood and the oth

They found:They found:● Varying ratios of platelets and pl● Plasma:RBC and platelets:RBC rp

decreased 6 h mortality▪ Patients with ratios < 1:2 were 3-4X

● Effect lost by 24 h● Effect lost by 24 h

Conclusion: early plasma/platConclusion: early plasma/plattrauma!

her stuff is good…her stuff is good…her stuff is good…her stuff is good…

lasma to RBC from admission to 24ratios were associated with

more likely to die (vs 1:1)

elets with blood is good inelets with blood is good in

Case: Mr. GCase: Mr. GCase: Mr. GCase: Mr. G

70 year old male70 year old maleUnbelted front seat / stationaryStruck by large truckStruck by large truckDifficult extricationSBP 70; obvious blood at the sSBP 70; obvious blood at the sTransported to QEII for Traum● (50 min post MVC)● (50 min post MVC)

GoodtimesGoodtimesGoodtimesGoodtimes

y car

scenescenema Team

NSTP TrauNSTP TrauNSTP TrauNSTP Trau

Boarded/collarBoarded/collarGCS 15, BP 70/30, RR 20, O2sat 99%, temp 35.9C%, pObvious bleed from scalp woundBilateral deformities of ankles

uma Teamuma Teamuma Teamuma Team

TraumTraumTraumTraum

Airway-breathing-circulationAirway breathing circulation

IV crystalloids (level 1)IV crystalloids (level 1)

Difficult IV intraossous inserDifficult IV…intraossous inser

Pelvis “loose” ”bound”Pelvis “loose” … ”bound”

ma 101ma 101ma 101ma 101

rtedrted

Should we “activate the maShould we “activate the maShould we activate the maShould we activate the ma

Yes!

“patient is bleeding with the anticipongoing blood loss…..”

When in doubt activateWhen in doubt activate…

ssive transfusion protocolssive transfusion protocolssive transfusion protocolssive transfusion protocol

pation of

Our approach inOur approach inOur approach inOur approach in

Diagnosis and treatDiagnosis and treat● Primary survey● Secondary surveyy y● Imaging and intervention

Avoid further bleeding ● Coagulopathy of trauma

trauma patientstrauma patients trauma patients trauma patients

Avoiding coagulopathy inAvoiding coagulopathy inAvoiding coagulopathy inAvoiding coagulopathy in

Principle: don’t make the patiePrinciple: don t make the patie

Easy:Easy: ● keep the patient warm

▪ Warm the room▪ Warm the patient▪ Warm the fluid

● Don’t “dilute” the patient▪ Use blood and minimize crystalloid

n the trauma resuscitationn the trauma resuscitationn the trauma resuscitationn the trauma resuscitation

ent worseent worse

CoagulopathCoagulopathCoagulopathCoagulopath

The lethal triad may be the consequence of the qresuscitation strategy

However many trauma patients arrive with the lethal triad even before resuscitation has begun

hy in traumahy in traumahy in traumahy in trauma

Coagulopathy in M(not all from r

Coagulopathy in M(not all from r

50% of patients undergoing mINR >2.01,2

(not all from r(not all from r

33% will have thrombocytope

24 28% will present with trau 24-28% will present with trau Consumption Hyperfibrinolysis

Severity of coagulopathy is a Severity of coagulopathy is a

1. Cosgriff N, Moore EE, Sauaia A, Kenny-Moynihan M, Burch JM, Galloway B. Predictinrevisited. J Trauma. 1997;42:857– 861, discussion 861–862

2. Harvey MP, Greenfield TP, Sugrue ME,et al. Massive blood transfusion in a tertiary re

3. Brohi K, Singh J, Heron M, Coats T. Acute traumatic coagulopathy.J Trauma. 2003;54g g p y

4. Gonzalez EA, Moore FA, Holcomb JB, et al. Fresh frozen plasma should be given ear

5. Tieu BH, Holcomb JB, Schreiber MA. Coagulopathy: its pathophysiology and treatme

6. MacLeod JB, Lynn M, McKenney MG, et al. Early coagulopathy predicts mortality in t

Massive Transfusion resuscitation )Massive Transfusion resuscitation )massive transfusion will have an

resuscitation…)resuscitation…)

enia <50x109/L1

uma induced coagulopathy3-5uma-induced coagulopathy3-5

associated with mortality6associated with mortality6

ng life-threatening coagulopathy in the massively transfused trauma patient: hypothermia and acidoses

eferral hospital. Clinical outcomesand haemostatic complications. Med J Aust 1995;163:356-9

4:1127–1130

lier to patients requiring massive transfusion.J Trauma 2007;62:112–9.

ent in the injured patient. World J Surg 2007;31:1055– 64.

rauma. J Trauma. 2003;55:39–44

Mr. GooMr. GooMr. GooMr. Goo

Unstable in trauma room

Crystalloid infused (warmed) as bloretrieved

Room warmed/Bare hugger appliesRoom warmed/Bare hugger applies

MTP activatedMTP activated● Call to transfusion services● Blood/plasma/platelets sent

P t t f TT● Porter part of TT

odtimesodtimesodtimesodtimes

ood

ss

What wWhat wWhat wWhat w

Blood:Blood:● Immediately● 6 units O-

Plasma 1.5L● Need to thaw● 12-22 minutes

Platelets 1 unit

we getwe getwe getwe get

NeNeNeNe

Blood arrives, administered ABlood arrives, administered A● Warmed: 4U

Platelets and plasma follow: a

Repeat VS BP 100/50, temp 35

“Stable” for CT

extextextext

SAP by nurseSAP by nurse

dministered asap

5.5C

AnythinAnythinAnythinAnythin

Tranexamic acidTranexamic acid

Just give itJust give it…

ng else?ng else?ng else?ng else?

GoodtimesGoodtimesGoodtimesGoodtimes

“stable in CT”stable in CTTo OR for pelvic stabilization● Ongoing blood productsOngoing blood products

▪ PRBC 12 U▪ Plates 3 units

Pl 2 5 L▪ Plasma 2.5 L

“goal directed”● Hgb> 80● Hgb> 80● Plts> 75● INR> 1.7INR 1.7

s in the CTs in the CTs in the CTs in the CT

GoodtimesGoodtimesGoodtimesGoodtimes

Admitted to ICUAdmitted to ICU

Hgb 98/platelets 230/INR 1 6Hgb 98/platelets 230/INR 1.6● “ooze”

1 U PRBC/day● No platelets or plasma requiredp p q

s in the ICUs in the ICUs in the ICUs in the ICU

97 Massive Trans97 Massive TransApril 1, 2013 to April 1, 2013 to

CDHA reported activationsCDHA reported activations ● 11 Trauma , 9 Medical, 76 Surgica● 28 Females, 69 Males

Tranexamic Acid - 31 patients

67 survived (69 1% survival)67 survived (69.1% survival)

sfusions at CDHA sfusions at CDHA March 31, 2014March 31, 2014

l, 1 Other

Key pKey pKey pKey p

Replace blood with blood and othepin trauma patients

Know when to activate MT and activ

Minimize secondary coagulation prMinimize secondary coagulation pr

Identify and fix surgical bleedingIdentify and fix surgical bleeding

Use transexamic acid

pointspointspointspoints

r good stuff g

vate early

roblemsroblems