Use of blood products. Evidence supporting their use. Massive transfusion protocol. Rotational thrombo-elastometry.

1. Use of Blood products in Trauma
Dr. W.G.P. Kanchana
Registrar in Surgery
Accident and Trauma Unit
NHSL

2. Introduction
• Traumatic injury contributes to about one in
ten mortalities, resulting in the annual
worldwide death of more than 5.8 million
people.
• Uncontrolled post-traumatic bleeding is the
leading cause of potentially preventable
deaths among injured patients.

3. Introduction
• Among the injured patients admitted to
trauma centres, up to 10% of military and up
to 5% of civilian patients require Massive
Transfusion.

4. Massive Transfusion
• Massive transfusion is defined, in adults, as
replacement of >1 blood volume in 24 hours
or >50% of blood volume in 4 hours (adult
blood volume is approximately 70 mL/kg)

5. Introduction
• We are basically going to talk about the
management of circulation in ATLS protocol.
A B C
Scientific basis and evidence of why we do
what we do!

6. Massive Transfusion Protocol

7. Massive Transfusion Protocol

8. Aims of resuscitation of circulation
• Maintain O2 carrying and delivery capacity of
circulatory system.
• Early Recognition / Prevent / Stop bleeding.
• Prevent vicious cycle of,
– Hypothermia
– Acidosis
– Coagulopathy / Early identification of
Coagulopathy

9. Fluid Resuscitation in Trauma
– World War 1: Preoperative resuscitation uncommon.
– World War 2: Resuscitation with fluids and blood.
– Vietnam War: 3 crystalloid : 1 RBC ratio.
– 1980s: Advent of damage control surgery.
– Middle East Conflict : United States Armed Forces added
plasma as a resuscitation fluid.

10. Crystalloids
• Nothings Normal about Normal saline except
for osmolarity.
• Not more than 1L of Normal saline
recommended in trauma resuscitation.
• Acidosis / Dilutional coagulopathy.

11. Colloids
• Twenty-five trials compared hydroxyethyl starch
(HES) to crystalloids in a total of 9147 patients,
demonstrating a beneficial effect in favour of
crystalloids. (Data from recent chocrane review)
• The authors concluded that there is no evidence
that resuscitation with colloids has any beneficial
effect on survival, and HES may even cause harm.
• Coagulation impairment, platelet function
impairment and renal impairment shown with
HES.

12. Fluid Resuscitation in Trauma

13. Fluid Resuscitation in Trauma
• In May 2005, based on reports from the ongoing
conflict in Iraq, an international expert
conference on massive transfusion hosted by the
US Army’s Institute of Surgical Research
introduced a new concept for the resuscitation
of patients with massive bleeding and
recommended the immediate administration of
coagulation components with a 1:1:1 ratio for
RBC, plasma and platelets.

14. RBC:Plasma Ratios
Plasma : RBC Overall mortality rate Hemorrhage mortality rate
1:8 65% 92.5%
1:2.5 34% 78%
1:1.4 19% 37%
• Retrospective. 246 MT patients. US combat
support hospital
• Plasma to RBC ratio independently associated
with survival

15. PROMMTT Study
• Prospective, Observational, Multicenter, Major
Trauma Transfusion (PROMMTT) – from 2009 to
2010
• Prospective cohort study. 1245 patients. 10 US Level
1 Trauma Centers.
• Increased plasma : RBC and platelets : RBC ratios
independently associated with decreased early
mortality, due to hemorrhage.
• Patients with ratios less than 1:2 were 3 to 4 times
more likely to die than patients with ratios of 1:1 or
higher.

16. PROPPR Trial (ongoing study)
• The follow-up Pragmatic Randomized Optimal
Platelet and Plasma Ratios (PROPPR) trial is a
randomized trial to evaluate ratios, MT patients
receive either a 1:1:1 (higher ratio) or a 2:1:1
(lower ratio) RBC: Plasma: Platelet with primary
outcome of survival, and also complications and
length of hospital stay.
• The results of this study should further elucidate
the optimal ratios of blood product
administration during MT.

17. Permissive Hypotension
• Two studies published in the 1990s
demonstrated increased survival when a low
and delayed fluid volume resuscitation
concept was used.
• Studies have shown higher mortality in
patients who received pre-hospital fluid
resuscitation than patients who did not.
• Higher incidence of coagulopathy in patients
receiving prehospital fluid resuscitation.

18. Permissive Hypotension
• Recommend use of a restricted volume
replacement strategy to achieve target blood
pressure until bleeding can be controlled.
(Grade 1B)
• Target systolic blood pressure of 80–90 mmHg
(Grade 1C)
• In patients with severe TBI (GCS ≤8),
recommended that a mean arterial pressure
≥80 mmHg be maintained.

19. Tranexamic Acid
• Tranexamic acid should be administered as
early as possible (with in 3 hours of injury) to
the trauma patient who is bleeding or at risk
of significant haemorrhage. (Grade 1A)
• Tranexamic acid is a synthetic lysine analogue
that is a competitive inhibitor of plasminogen.

20. Tranexamic Acid
• Clinical Randomisation of Antifibrinolytic
therapy in Significant Haemorrhage (CRASH-2)
trial.
• assessed the effects of early administration of
a short course of TXA on death, vascular
occlusive events and the receipt of blood
product transfusion in trauma patients.

21. Tranexamic Acid
• CRASH-2 Trial Results
– All cause mortality was significantly reduced
– risk of death due to bleeding was significantly
reduced.
– Reduction in bleeding deaths by one-third, mainly
through preventing exsanguination
within the first 24 h.
– rate of venous thromboembolism (VTE) was not
altered.

22. Coagulopathy in Trauma Patients
• Upon hospital admission about one-third
of all bleeding trauma patients already show
signs of coagulopathy.
• A significant increase in the occurrence of
multiple organ failure and death compared to
patients with similar injury patterns in the
absence of a coagulopathy.

23. Coagulopathy in Trauma Patients
• Different Terms
– Acute Traumatic Coagulopathy
– Early Coagulopathy of Trauma
– Acute Coagulopathy of Trauma-Shock
– Trauma-Induced Coagulopathy
– Trauma-Associated Coagulopathy

24. Coagulopathy in Trauma Patients
• The early acute coagulopathy associated with
traumatic injury has recently been recognized
as a multifactorial primary condition.
• Due to,
– bleeding-induced shock
– tissue injury-related thrombin-thrombomodulin-
complex generation
– activation of anticoagulant and fibrinolytic
pathways

26. Assessment of coagulopathy in
Trauma
• Divergence in the initial management of
patients following traumatic injury, depending
on the availability of rapid point-of-care
coagulation testing to facilitate goal-directed
therapy.
• Goal Directed Vs Fixed Ratio regimes

27. Assessment of coagulopathy in
Trauma
• Early monitoring of coagulation is essential to
detect trauma-induced coagulopathy and to
define the main causes, including
hyperfibrinolysis.
– Early therapeutic intervention does improve
– reduce the need for transfusion of RBC, FFP and
platelets
– reduce the incidence of post-traumatic multi-organ
failure
– shorten length of hospital stay
– improve survival

28. Goals of Coagulation Resuscitation
• Ionised calcium (Ca) >1.1 mmol/L
• Platelet (Plt) >50 x 109 /L
• PT/APTT <1.5x of normal
• INR ≤ 1.5
• Fibrinogen >1.5 g/L

29. Coagulation Monitoring
• Early, repeated coagulation monitoring
including laboratory measurements,
– PT/INR
– APTT
– Platelets
– Fibrinogen
– viscoelastic methods – TEG, ROTEM

30. Coagulation Monitoring
• Static laboratory tests take time and invariably
lead to delay in management.
• Point of care testing with TEG provide
effective and convenient means of monitoring
whole blood coagulation.
• It evaluates the elastic properties of whole
blood and provide a global assessment of
haemostatic function.

31. TEG / ROTEM
• Traditional thromboelastography (TEG®) method,
developed by Dr. Hellmut Hartert in 1948.
• Thromboelastometry is a viscoelastometric
method for haemostasis testing in whole blood.
• It measures the interactions of coagulation
factors, inhibitors and cellular components during
the phases of clotting and subsequent lysis over
time.

32. Basics of Thromboelastography

34. TEG / ROTEM

35. Parameters in TEG
• R-time – latancy from start of test to initial
fibrin formation. (5-7mins when kaolin
activated)
• K-Time – Time taken to achieve a certain clot
strength. (time for amplitude of 20mm –
normal 1-3 mins when kaolin activated)
• Alpha angle – Speed of fribrin build-up. Rate
of clot formation.
• MA – Ultimate clot strength, correlates to
platelet function.

36. Parameters in TEG
• LY30 – percentage decrease in amplitude 30
mins post MA – measure of degree of
fibrinolysis.
• EPL – Computer prediction of 30mins lysis
based on rate of diminution of trace
amplitude commencing 30sec post-MA
(earliest indicator of abnormal lysis)

37. Example TEG Tracings

38. FFP

39. FFP - Complications
• Circulatory overload
• ABO incompatibility
• Transmission of infectious diseases
• Allergic reactions
• Transfusion-related acute lung injury
• Plasma transfusions cannot contribute to a
significant increase in fibrinogen level
• Issuing of plasma takes time due to need for
thawing and warming

40. Fibrinogen

41. Fibrinogen
• it is shown that high-dose fibrinogen
administration resulted in improved
coagulation and a reduction in coagulopathy.

42. Platelets

43. Calcium

44. Patients on Antiplatelet Therapy

45. Desmopressin

46. PCC

47. Patients on New Anticoagulation
Treatment

48. Thromboprophylaxis after trauma
• Pharmacological thromboprophylaxis should
be employed within 24 h after bleeding has
been controlled.
• Early mechanical thromboprophylaxis with
intermittent pneumatic compression should
be applied and early mechanical
thromboprophylaxis with anti-embolic
stockings may be applied.

49. References
• 2016 European guideline on management of
major bleeding and coagulopathy
following trauma: fourth edition
• Thakur M, Ahamed AB. A review of
thromoboelastography. Int J periop Ultrasound Appl
Technol 2012;1(1):25-29

50. Thank You!!