This document discusses trauma resuscitation and massive transfusion protocols. It begins by presenting a case of a hypotensive trauma patient and examines signs of hemorrhagic shock. It then discusses the negative consequences of aggressive crystalloid resuscitation and promotes damage control resuscitation using a balanced ratio of blood products instead. The key components of developing an effective massive transfusion protocol are outlined, including triggers for activation, product ratios, and adjuncts like antifibrinolytics. Collaboration between specialties is emphasized for creating and continually improving institutional protocols.

1. Giving blood in trauma-
It’s not that simple!
Andrew J. Kerwin, MD, FACS
University of Florida Department of Surgery
UF Health Jacksonville, Trauma Medical Director

2. Patient
 58 y M unhelmeted bicycle rider struck by car
 Rolled off hood & thrown 15 ft
 Intubated in field due to low GCS
 Hypotensive in field
 Hypotensive on arrival

5. 0
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SBP HR

6. 0
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SBP HR
Binder

8. Does this patient
exhibit signs of
bleeding?

9. 4 Classes of Hemorrhagic Shock

10. Large Bleeding Producing Shock

11. Large bleeding producing shock

12. How do we resuscitate
this patient?

14. What are the Consequences?
 “Pop the clot”
 Uncontrolled hemorrhage
 Capillary leak
 Multiple negative systemic effects
AGGRESSIVE CRYSTALLOID RESUSCITATION

15. Consequences
Crystalloid causes severe
resuscitation injury!

16. Consequences of
uncontrolled hemorrhage

17. Fluid type/ amount Mortality (%)
Colloid 7.1
< 3L crystalloid 23.1
3-6L crystalloid 40.0
> 6L crystalloid 45.5
Guidry C, et al. J Surg Research. 2013
CRYSTALLOID IS BAD

18. How do we manage
the bleeding?

19. Coagulation Cascade
This is simple?
Simple: Damage Control Resuscitation

20. Damage Control Resuscitation
 Minimize crystalloid infusion
 < 500 mL
 Permissive hypotension
 Avoid “pop the clot”
 Stop the bleeding
 Transfusion of a balanced ratio of blood products
 Goal directed correction of coagulopathy
MASSIVE TRANSFUSION PROTOCOL
(MTP)

21. What constitutes MTP?
 Transfusion > 10u PRBCs in 24 hrs
 Transfusion >4u PRBCs in 1hr with anticipated
need for more
 Transfusion > 6u PRBCs in 6 hrs
 Transfusion > 5u PRBCs in 4 hrs
 Replacement of >50% of total body volume by
blood products within 3 hrs
Rapid supply of blood products in
exsanguinating patients

22. Why develop a MTP?
Advantages
• Rapid supply
• Sustained supply
• Improves mortality
Disadvantages
• Time consuming
effort
• Wastage
• Confusion
• Ratio?
• Batch content?
• Batch size?
• Trigger?

23. What is it a MTP?
 Written document to establish:
 Triggers
 Ratios and batch size
 Process for immediate availability of products
 Assessment of coagulopathy
 Assessment and treatment of:
 Acidosis
 Hypothermia
 Hypocalcemia
 Transfusion targets
 Termination of MTP
 Performance improvement monitoring

24. Traumatic Coagulopathy
Simmons JW & Powell MF. Br J Anesth.2016

25. Who should develop a MTP?
 Multidisciplinary collaboration of:
 Trauma surgeons
 Emergency Medicine
 Anesthesiology
 Pathology
 Transfusion services
 Blood bank
 Nursing

26. When should we
activate the MTP?

27. MTP Activation Triggers
 TASH (Trauma Associated Severe Hemorrhage)
 ABC (Assessment of Blood Consumption)
 MTS (Massive Transfusion Score)
 MTS revised
 CITT (Cincinnati Individual Transfusion Trigger)
 Schreiber Score
 McLaughlin score
 ETS (Emergency Transfusion Score)
 PWH (Prince of Wales Hospital Score)
 Gestalt

28. When should we activate MTP?
Camazine MN, et al. J Trauma. 2015
Cantle PM, Cotton BA Crit Care Clinics 2017

29. ABC score is a simple trigger for MTP

30. How much blood
should we
transfuse?

31. Why 1:1:1 ratio?

32.  Received at least 1 u PRBC
 Early plasma transfusion
 Reduced PRBCs transfused at 24 hrs
 Reduced in hospital mortality
 No demonstrated benefit to early platelet transfusion
Del Junco DJ, Holcomb JB, et al. J Trauma. 2013

33.  Received at least 3 u PRBC
 Early plasma & platelet transfusion
 Reduced mortality at 6 hrs
PROBLEM: Did not follow a constant transfusion ratio
Holcomb JB, et al. JAMA Surgery. 2013

34.  1:1:1 ratio
 More achieved hemostasis
 Fewer exsanguination deaths
 No difference in complications
 No difference in mortality
Holcomb JB, et al. JAMA Surgery. 2015

35. Glaser J, et al. J Trauma. 2015

36. What about adjuncts
to MTP?

37. Storage and Transportation

38. Fibrinolysis

39.  Blocks lysine binding on plasminogen, prevents
conversion to plasmin and blocks fibrinolysis
 Given to patients with significant hemorrhage
 SBP< 90, HR >110
 Within 8 hrs of injury

40. Conclusions
 Crystalloid resuscitation is bad!
 MTP is important in rapidly bleeding patients
 Clear definition of MTP would be useful
 Collaboration is essential
 Development
 Monitoring
 Process improvement
 Refinement