Massive Transfusion in Trauma
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Massive Transfusion in Trauma
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Massive Transfusion in Trauma
- 1. MASSIVE TRANSFUSION in traumaDr Gaynor Prince 2015 GOAL DIRECTED COAGULATION MANAGEMENT
- 2. Definition Adults - replacement of >1 blood volume in 24 hours or >50% of blood volume in 4 hours Children - transfusion of >40ml/kg
- 3. When should MTP be triggered? Senior clinician - suspects impending or established hemorrhagic shock in a bleeding pt Scoring systems Thromboelastography
- 4. Assessment of Blood Consumption (ABC) Score ED SBP <90mmHg ED HR >120bpm Penetrating Mechanism Positive FAST 3 = 45% chance MT 4 = 100% chance MT
- 5. TEG and ROTEM A few things to know... Viscoelastic haemostatic assay measures - global visco-elastic properties of whole blood clot formation under low shear stress What does this mean???
- 8. TEG and ROTEM = interaction of platelets and the coagulation cascade Assess the entire coagulation process - fibrin formation, clot - rate, strength, stability and lysis Diagnose Trauma induced Coagulopathy (TIC)
- 10. Thromboelastogram Use prediction of need for transfusion Guide transfusion strategy trauma studies - reduction in blood product use and mortality
- 15. Availability Red cell O neg - immediate ABO Group specific - 15 min Crossmatched - 45 min FFP - 30 min Platelet - on site = immediate, otherwise hourly min
- 16. Actions HISTORY Age, Gender MOI Pre-hospital fluids/Blood Components PMHx - coagulopathy Meds - warfarin, clopidogrel, aspirin Previous tranfusion rxn/antibodies
- 17. Actions Control bleeding - early surgical involvement AVOID excess crystalloid use Bloods - Crossmatch ABG FBC, U&E, Ca Coag profile/ROTEM
- 18. Actions Notify Transfusion Medicine Unit EXT 2783/PG 4415 Request Major Hmg Pack...
- 19. AVOID HYPOTHERMIA ! HYPOTHERMIA !Fluid warmer - level 1 Bair Hugger Minimise exposure Monitor Temperature
- 20. Ongoing Shock Request more product & inform Haematologist Pack A 1 unit adult platelets 2 units RBC 2 units FFP Check results and repeat bloods - 30-60 min Pack B - 2 Units RBC - 2 Units FFP
- 21. Blood Component Ratio Guideline 1:1:1 1 adult unit platelets = 4 units RBC = 4 units FFP PROPPR trial - Pragmatic Randomised Optimal Platelet and Plasma Ratios Trial
- 22. OPTOMISE
- 23. Aims Temp >35ºC pH >7.2 Base Excess >-6 Lactate <4 Ca >1.1mmol/L Platelets >50 x 109/L PT/APTT < 1.5 normal INR <=1.5 fibrinogen>1.0g/L
- 24. Adjuncts Tranexamic acid - within first 3 hours of trauma ideally 1g over 10min then infusion 1g over 8 hours CRASH 2 Trial - 2010
- 25. Adjuncts Cryoprecipitate - if fibrinogen <1g/L or ROTEM indicates NB in obstetric and trauma bleeds 1 dose cryo = 8 units Ca Chloride 10ml 10% if Ca2+ <1.1mmol/L
- 26. Special Situations Warfarin reversal NOAC Head Injury Heparin reversal
- 27. rFVIIa Routine use in trauma - NOT recommended Consider use if uncontrolled hmg in salvagable pt AND failed surgical/radiological measures to control bleeding AND adequate blood component replacement AND Plt count >50 pH >7.2 Temp >34 Contact Haematologist
Editor's Notes
- 10U transfusion in 24 hours blood volume children - 80ml/kg
- ABC Score, TASH Score, McLaughlin score
- Yes =1 No = 0 TASH - Trauma associated severe haemorrhage - SBP, Gender, Hb, +ve FAST, HR, BE, extremity or pelvic # Mclaughlin Score - HR &gt;105, SBP &lt;110, pH &lt;7.25, Hct &lt;32%
- TEG - thromboelastography - developed in 1948 - pre dates PTT, rapid POCT ROTEM - rotational thromboelastometry Traditional assays - take too long, designed to evaluate levels of factor in the plasma. Not designed to evaluate the haemostatic process which is what we want to know in TIC
- CLot formation platelet aggregation coagulation cascade fibrin formation Trapping cells fibrinolysis
- TIC - imbalance of dynamic equilibrium btw procoagulant factors, anticoagulant factors, platelets, endothelium and fibrinolysis
- Studies show cost effectiveness and reduction in blood products in liver transplant and cardiac surgery
- CT - time from start of test to initiation of clot - normal - clotting factor normal CFT - time from initiation of clotting to a clot firmness of 20mm Alpha angle - used to look at platelet function and fibrinogen MCF - clot quality ML - reduction of clot firmness after MCF in relation to MCF - stability of clot (ML &lt;15%) or fibrinolysis (ML &gt;15% within 1 hour)
- Normal ROTEM results EXTEM and FIBTEM - indicates platelet and fibrinogen abnormalities - used in trauma INTEM and HEPTEM - heparin influence or intrinsic pathway factor deficiency EXTEM and APTEM - detects hyperfibrinolysis EXTEM - external clotting cascade - factor 7 - issue with warfarin INTEM - Intrinsic pathway of clotting cascade - heparin causes derangement FIBTEM - looks specifically at fibrinogen APTEM - ?fibrinolysis - add apoprotinen to block firbinolysis Normal amplitudes - platelet contribution is sufficient and fibrinogen level sufficient
- Alpha angle - blunted - platelet dysfunction or lack of plt. ?plt or fibrinogen def...look at fibtem - thick clot formation
- EX, IN normal FIBTEM - fibrinogen def
- FFP and platelets will be needed earlier if pt been transfused pre-hospital
- Others - Calcium
- 1st batch of MTP - 4 units of RBC and 2 Units thawed FFP Availability - immediate - do need warning to thaw FFP so activate if suspicious
- Randomised 2 group, Phase III trial, pts at level 1 trauma centres requiring MTP 1 of 2 groups - 1:1:1 or 1:1:2 - plasma, platelet, RBC Co-primary mortality endpoints @ 24hr and 30 days evaluated 680 pts randomised over 16 months
- OXYGENATION CARDIAC OUTPUT - permissive hypotension until bleeding controlled (CI in head injury TISSUE PERFUSION metabolic state Temperature
- MOA - antifibrinolytic. Inhibits plasminogen activation and plasmin activity - prevents clot breakdown. Crash 2 trial - tranexamic acid reduced all cause mortality in a broad population of trauma patients without an increase in vascular occlusion -randomised, placebo controlled trial - 20211 trauma pts with significant hmg, within 8 hours of initial injury and &gt;16years old - randomised tranexamic acid vs placebo -endpoint - hospital mortality within 4 weeks of injury reduced 14.5% vs 16% NNT 66 - endpoint - death due to haemorrhage reduced - 4.9 vs 5.7% - NNT 125 - No difference in blood transfusion or blood products used - questions beneficial mechanism of Tx acid
- Cryo - blood product - centrifuged FFP Cryo contains - firbrinogen, Factor 8, vWB factor, Factor 13 Compatibility testing not required Fibrinogen - glycoprotein, converted by thrombin to fibrin
- Warfarin Reversal - 5-10mg vit K, prothrombinex 25-50units/kg, FFP 1-2units NOAC - contact haematology Head Injury - Aim Plt &gt;100, permissive hypotension Contraindicated Heparin reversal - 1mg Protamine for every 100 U heparin within 4 hours of ceasing. Use aPTT to guide further doses - contact haematologist
- dose 100mcg/kg to nearest vial Not licensed for use in this situation - all use will be reviewed