‘’An acute transfusion protocol for severe blunt trauma, and what we might do when

FFP is not immediately available’’

Kotaro Sorimachi

Fukushima Medical University

Emergency and Critical Care Medicine

Introduction

• It’s important for patients with massive bleeding due to severe blunt trauma to transfuse early, especially to maintain or restore hemostasis.

•Protocol for massive transfusion is useful for fast response in emergencies.

Clinical Question

Is our protocol effective for hemostasis and survival?

Our hospital’s protocol

• Severe blunt trauma• Unstable pelvic fracture is suspected• FAST (Focused assessment with sonography for trauma) (+)

Shock vitals+

6 units* of type O Red Cell Concentrates (RCC)

4 units* of type AB Fresh Frozen Plasma (FFP)

First information

Order before arrival

*A “unit” in Japan is based historically on a 200 mL whole blood donation.

Period : 1 year (Jan – Dec 2016)

Number : 15 (Male : 10)

★Average utilization★

RCC 3.5 units/patient

FFP 0.2 units/patient

How often did we use this protocol ?

Why the low utilization of FFP?

• Thawing time : about 20 min

• Fibrinogen concentration : 0.16-0.2 g/dl

Massive transfusion of FFP = Dilutional coagulopathy ??= acquired hypofibrinogenemia

New protocol

• Prepare: MAP + FFP + Fibrinogen 3-6g

• Measure fibrinogen level with ROTEMalong with other lab tests.

(decide the amount of fibrinogen depending on the level)

https://www.rotem.de/en/products/rotem-sigma/

Case using new protocol

30-year-old male

• Traffic accident (car vs car) due to drowsy driving• Head-on collision at 60 km/h

• “Unconscious, in shock” - Ambos→put “Massive Transfusion Protocol”

into action

Vital signs• SpO2 96% (O2 10L), RR 14/min

• BP unmeasurable, HR 114/min, FAST(-)

• GCS E1V1M1, pupils 5mm(-)/5mm(-)

Hemorrhagic shock due to multiple traumatic injuries

traumatic SAHpelvic fracturefemoral shaft fracture

intraperitoneal bleeding

elbow open fracture radial fracture

• ISS（Injury Severity Score）

• RTS（Revised Trauma Score)

• Ps (Probability of survival)

272.33

0.307

First results of ROTEM

MCF : maximum clot firmness

MCF<10mm→hypofibrinogenemia

FIBTEM→for evaluation

・fibrinogen concentration・fibrinogen polymerization reaction

Passage of time

0 15 33time (minutes)

arrivalFibrinogen 6g started

21 30

Fibrinogen 6g started

first ROTEM exam hypofibrinogenemia

RCC transfusion started

Blood test

SpO2 96% (O2 10L), RR 14/minBP unmeasurable, HR 114/min, GCS E1V1M1, pupil 5mm(-)/5mm(-)FAST(-)

Fibrinogen concentration

Before After

fibrinogen : 6g

After recovery of his coagulation system: Hemostasis

IABO inflation

External fixation : pelvis

Laparotomy hemostasis

After initial damage control surgery and subsequent operations, he was transferred to

another hospital for rehabilitation.

DiscussionIs fibrinogen really effective?

• Fibrinogen from thrombin cascade:1 thrombin molecule converts ~1,700 fibrinogen molecules

• When bleeding persists, fibrinogen levels are inadequate to maintain hemostasis.

(Seppo T at el, Hemostatic Factors and Replacement of Major Blood Loss with Plasma-Poor Red Cell Concentrates, Anesth Analg 1995;81:360-5)

For hemostasis…Consider “Concentrated fibrinogen factor” in early term.

Issues

• Fibrinogen infusion isn’t approved for acquiredhypofibrinogenemia.

• 1g fibrinogen needs about 12 persons’ blood donation→expensive (~US$286.50)→theoretical infection risk

• Infusing fibrinogen might improve survival in massive bleeding due to severe blunt trauma.

• Rapid testing and infusion can be incorporated into a massive transfusion protocol.

• Royal Big Smoke? Outback Base? Your thoughts…

Take home message

N(not to scale)

Fukushima Australia