Massive transfusion protocols aim to replace lost blood volume and prevent coagulopathy in severely injured trauma patients. The study found that 7% of trauma patients received over 10 units of red blood cells in the first 24 hours, identifying them at high risk. Early administration of blood products in a 1:1:1 ratio of red cells, plasma, and platelets according to massive transfusion protocols was associated with reduced mortality compared to standard transfusion practices. Simple clinical factors like low blood pressure, high injury severity score, and coagulopathy can help predict patients needing massive transfusion.

1. Massive transfusion in trauma R.Sinha, D.Roxby, R.Seshadri Flinders Medical Centre, SA

2. Massive transfusion Massive transfusion – a response to uncontrollable haemorrhage Must be timely and directed at volume replacement ,oxygen delivery, prevention and correction of coagulopathy Opportunities and risks

3. Who needs massive transfusion In a study of 5646 trauma patients by Como & colleagues - 2.5% received more than 10 units of red cells during their admission American military casualty study 8% received massive transfusion Como JJ,Dutton RP,Scalea TJ,Edelman BB Hess JR.Blood transfusion rates in the care of trauma deaths. Transfusion 2004;44:809-813 Borgman et al. The ratio of blood products transfused affects mortality in patients receiving massive transfusion at a combat support hospital. J trauma 2007;63:805-813

4. Aspects of massive transfusion Identifies a group with severe injury Use a large resource Focus of research damage control surgery 1:1:1 ratio of RC:FFP:PLT thawing of plasma transfusion protocols

5. Aims of the study Evaluate the massive transfusion practice Factors associated with massive transfusion Outcomes Methods Trauma patients admitted during 1998 to 2006 Patients who received ≥10 units of red cells in the first 24 hours of injury Linked with other databases

6. Results TOTAL 6488 trauma patients 438 (7%) received transfusion 358 received 1-9 red cells and 80 received ≥10 red cells. Major trauma (ISS>15) - 1021 patients 313 (30%) were transfused ISS [16-24] - 19% ISS [25-49] - 45% ISS [50-75] - 8%

7. Massive Transfusion - Demographics Median Patients 80 Age (years) 35 (23-51) M:F 3.5:1 Blunt injury 92% Time from accident to hospital 112 minutes Coagulopathy 74% ICU length of stay 5 (1-13) Hospital length of stay 21 (2-50) Mortality 33% .

8. Injury Severity Score (ISS) ISS (median) Overall 38 (27-48) Survivors 29 (22-41) Non-survivors 49 (41-57 )

9. Injury regions 80% of the patients had multiple injuries 08 (10%) Injury to extremities 09 (11%) Facial injuries 47 (59%) Limbs 38 (48%) Injuries to abdomen and pelvis 51 (64%) Chest injuries 42 (53%) Head or neck injuries Patients (%) Different regions

10. Blood products used Units 24hrs Median,IQR Units 6hrs Median,IQR 1603 18 (12-28) 1221 13 (9-20) Red cells 679 7 (4-11) 431 4 (2-8) FFP 145 2 (1-3) 80 1 (0-2) Platelets 12 0 4 0 Cryo 2.5 (1.8-3.3) 2.8 (2.0-3.8) RC:FFP 11(9-12) 11(9-15) RC:PLT

11. Blood products used 0.20 21(13-31) 17 (12-23) RC (24hrs) 0.40 8 (5-13) 6 (4-10) FFP (24hrs) 0.41 2(1-3) 1 (1-3) PLTS (24hrs) 0.66 2.4:1 2.5:1 RC:FFP (24hrs) 0.85 11:1 10.5:1 RC:PLT (24hrs) 26 54 Patients 0.01 18(11-26) 12 (9-17) RC (6hrs) 0.03 7(4-9) 4 (2-8) FFP (6hrs) 0.02 1(0.8-2) 2 (0-1) PLTS (6hrs) 0.60 2.6:1 2.8:1 RC:FFP (6hrs) 0.78 11.4:1 11:1 RC:PLT (6hrs) p-value Non-survivors Survivors

12. Where are they transfused? 21% of the total units transfused –uncrossmatched O negative or group specific units ICU OT Resuscitation Retrieval Location 57 ( 71%) 60 (75%) 56 (70%) 24 (30%) Patients

13. Can we predict who needs MT? Simple clinical algorithms to allow recognition of patients at the risk of MT McLaughlin et al 1 - Heart rate >105 Systolic BP <110 mm of Hg, pH<7.25Hct <32% Schreiber et al 2 ≤11g/dl,INR>1.5,penetrating injury Yucel et al 3- TASH score- HR,BP,Hb,BEXS,pelvic & femur fracture 1 J Trauma. 2008;64:S57–S63. 2 J Am Coll Surg. 2007;205:541–545 . 3 J Trauma. 2006;60:1228 –1237 .

14. Risk factors for the need of massive transfusion p-value OR 95%CI SBP <90 <0.001 3.8 1.8-7.8 (systolic blood pressure) Hb <120g/L 0.002 3.6 1.6-8.0 ISS>15 < 0.001 5.3 2.8-10

15. Outcomes Overall mortality 26/80 (33%) Early Mortality 19/26 (73%) Discharged home/Rehab 44 (55%) Other hospitals 7 (9%) Other 2 (3%)

16. Approaches to massive transfusion No strict guidelines for transfusion practice in major trauma Recent military experience - 1:1, FFP: RBC is independently associated with improved survival. 1:1 or 1:2 for civilian trauma – the optimal ratios yet to be defined. Based on these studies institutions have implemented massive transfusion protocols.

17. Massive Transfusion Pack

18. Schedule for Massive Transfusion Response Pack RC FFP PLT Cryo rFVIIa 1 5 (O Neg) 2-4 (AB) 1 2 5 4 2 2 3 5 4 2 2 *** 4 5 4 2 5 5 4 2 6 5 4 2 2 7 5 4 2 8 5 4 2 9 5 4 2 2 10 5 4 2

19. Case study 66 yo male: 6m fall, crushed by falling truss Injury time-13.05 ED arrival- 14.19 SBP- 60 CT scan-Open book fracture pelvis 15:01 – angio-embolisation of bilateral bleeders OT - 18:14-19:02 -17 packs placed in deep pelvis Patient survived 5 RC 2 FFP 1 SDP 1 CRYO 5 RC 4 FFP 1 SDP 1 CRYO 5 RC 2 FFP 1 SDP 5 RC (O Neg) 2 FFP (AB) 1 SDP MTP4 16.23 MTP3 16.10 MTP2 15.15 MTP1 14.24

20. Summary Massive transfusion identifies a group of trauma patients with severe injury increased risk of coagulopathy potential benefit of 1:1:1 blood products Simple variables (SBP,ISS, coagulation parameters) can predict the need for massive transfusion for trauma patients

21. Thank you