Damage Control Resuscitation

Damage Control Resuscitation

Mazen Kherallah, MD, FCCP

Executive Director of Quality Assurance

SEHA: Abu DhabiInfectious Disease & Critical Care Medicine Consultant

Sheikh Khalifa Medical City

1

Outline

Introduction Damage Control Resuscitation Data from the Battlefield

Plasma Platelets Fresh Whole Blood

Conclusion

Definition of Massive Transfusion Replacement of a blood volume

equivalent within 24hr

>10 unit within 24 hr

Transfusion > 4 units in 1 hr

Replacement of 50% of blood volume in 3hrs

A rate of loss >150ml/hr

Hemorrhaging Trauma Patient:Case Report*

24 y/o Iraqi special forces soldier Multiple high-velocity GSW through-

and-through flanks and pelvis. Arrived via helicopter. Unknown pre-hospital time.

*courtesy of Dr. Al Beekley

Arrival SBP ~50

Injuries

Left lobe of liver laceration

Through-and-through distal esophagus

6 gastrotomies Splenic rupture Proximal splenic artery

injury Distal pancreas

laceration Left kidney laceration

Multiple small bowel enterotomies

Evisceration of omentum through left flank

Bladder injury Extra-peritoneal rectal

injury Pelvic fracture Internal iliac artery and

vein lacerations Left open tibia/fibula

fracture

21

33

30

29

Introduction: Battlefield Medicine

How would you transfuse (resuscitate) this type of casualty?

Introduction: Trauma/Coagulopathy

Hemorrhage is the leading preventable cause of death from trauma

Resuscitating these casualties requires some understanding of why they are bleeding …and continue to bleed despite getting transfused

Hemostasis in Trauma

• Majority (90-95%)

- Non-severe

- Inflammation

- Hypercoaguable

- DVT / PE

• Minority (5-10%)

- Severe Trauma

- Consumption, Dilution

- Hypocoaguable

- Hemorrhagic Shock

Coagulopathy of Trauma

“trauma triad” of hemorrhage, acidosis, hypothermia

Dilutional coagulopathy Excessive use of crystalloid, RBCs

Consumptive coagulopathy Hyperfibrinolysis

20% on admission with ISS>15

Acute coagulopathy of trauma

Haemorrhage

Hypotension

Resuscitation

Haemodilution

Coagulopathy

Hypothermia

Complications of massive transfusion

The Lethal Triad

AcidosisAcidosis HypothermiaHypothermia

CoagulopathyCoagulopathy

Death

Brohi, K, et al. J Trauma, 2003.

Coagulopathy of trauma

Brohi, K, et al. J Trauma, 2003.

Blood loss

DilutionalAcidosis

Hypothermia

Consumption

Increased fibrinolysis

Acute Coagulopathy of Trauma

Thermal Coagulopathy

The coagulation cascade is an enzymatic pathway that degrades with temperature and ceases at 92 F

Hypothermia slows the enzymatic reactions of the coagulation cascade

Hypothermia prevents the activation of platelets by traction on the glycoprotein 1b, IX, V complex by von Willebrand factor (VWF)

A temperature < 96°F or 35°C is associated with an increase in mortality.

Dilutional Coagulopathy

Coagulopathy associated with trauma and massive transfusion –dilutional

Plasma-poor RBCs dilutes coagulation factor concentrations

Collins. Massive transfusion and current bloodbanking practices. In: Preservation of Red Blood Cells. National Academy of Sciences:

Washington, DC; 1973:39-40

• Loss of blood• Critical requirements for fluid, volume, red cells, albumin

Critical dilution for coagulation factors occur after loss of 1.2 blood volumes and for platelets at 2 blood

volumes

Acidotic Coagulopathy

Acidosis – interferes with the assembly of coagulation factor complexes

Acidosis contributes more to coagulopathy more than hypothermia (not reversible)

Consumption Coagulopathy

Consumption of coagulation factors and platelets – highly localized at site of injury

Subendothelial smooth-muscle cells, Fibrobasts

TF

TF

TF

FVII

Nanomolecule of TF present in every square meter of fibroblasts or smooth-muscle cell – all of FVII could be removed from the circulation by 3-30m2 of endothelial disruption

Schester, Glesen Taby, et al 1997

Dietzen, Page Tetzloff, 1997

Increased fibrinolysis Generation of thrombin at injury sites leads

to its binding to thrombomodulin on normal endothelium with activation of protein C

Reduced local thrombin concentrations lead to thin fibrin strands with high surface-to-volume ratios and prevent the activation of TAFI (thrombin-activated fibrinolysis inhibitor)

Low vascular flow leads to release of tissue plasminogen activator (tPA) from intact endothelial cells

Acute Coagulopathy of Trauma

Very early within 10 min of arrival Hypoperfusion and shock (oxygen debt)

Anti-coagulation and hyperfibrinolysis Increased soluble thrombomodulin

Increased activated protein C Decreased utilization of fibrinogen Decreased plasminogen activator inhibitor

No coagulation factor deficiency or dysfunction at this early time.

Brohi K. Acute Coagulopathy of Trauma. J Trauma. 2008:64(5);1211-1217

New Diagnostic criteriaAvoids the “but he looked good” phenomenon New Diagnostic criteria

Avoids the “but he looked good” phenomenon

Within the first five minutes in the ED Identify patients in trouble Identify patients with increased mortality Identify patients with increased probability of massive

transfusion

Patients At Risk for Massive Transfusion: MT

A systolic blood pressure of 90 mm Hg or less is indicative casualties

that have lost over 40% of their blood volume (2000 mL): Increased

Mortality

Otherwise young healthy soldiers with a Hgb of < 11 have

only one reason for their anemia, namely acute blood loss

Acidosis: Base deficit (BD) ≥ 6 Initial INR ≥ 1.5: Severity of

injury and mortality is linearly associated with the degree of

the initial coagulopathy

Patient At Risk

23

Hypothermia < 96.5

Outline

Introduction Damage Control Resuscitation Data from the Battlefield

Plasma Platelets Fresh Whole Blood

Conclusion

Haemorrhage

Hypotension

Resuscitation

Haemodilution

Coagulopathy

Hypothermia

Complications of

massive transfusion

Crystalloid:PRBCs 3:1 Ratio

How to Resuscitate these PatientsDamage Control Resuscitation

Hemostatic resuscitation

Hypotensive resuscitation

Bleeding Control

Permissive hypotension: Minimize rebleed: avoid

“popping the clot”

First “patching up the holes,” and delaying definitive careEarly surgical control of bleeding

Prevent/treat: acidosis, hypothermia, hypocalcemia,

coagulopathy

Hemostatic ResuscitationHemostatic Resuscitation

Early Dx in ED

Warm Fresh Whole Blood (WFB)

1:1:1 ratio of Plasma: RBC: PLT

Aggressive use of cryo and platelets

ED use of rFVIIa and repeated doses in OR and ICU as required

Limit excessive use of RBCs & crystalloids

Use RBCs of decreased storage age

Outline

Introduction Damage Control Resuscitation Data from the Battlefield

Plasma Platelets Fresh Whole Blood

Conclusion

Data from the Battlefield

Recent conflicts in Iraq and Afghanistan have provided means for the study large numbers of severely injured patients

Military medicine has made an effort to be data driven

Joint Theater Trauma Registry We’ll look at three studies:

FFP:RBC ratio Platelet:RBC ratio Warm Fresh Whole Blood

FFP:RBC Ratio study

246 massively transfused patients at a Combat Support Hospital

Divided into 3 FFP:RBC ratio groups <1:4, 1:2 - 1:4, >1:2 Compared baseline demographics and outcomes

Performed multivariate regression analysis for overall mortality

Borgman, MA, Spinella, PC, et al. “Ratio of blood products affects mortality in trauma,”J Trauma 2007:63(4); 805-813

20%

34%

65%

0

10

20

30

40

50

60

70

0:22 - 1:4 1:3.9 - 1:2.1 1:2 - 1:0.59

Mor

talit

y

Chi SquareLow to Med: p=0.01Med to High: p=0.02

Effect of FFP:RBC ratio on overall mortality

n=31 n=56 n=165

FFP:RBC RatioBorgman, MA, Spinella, PC, et al. “Ratio of blood products affects mortality in trauma,”J Trauma 2007:63(4); 805-813

0:22 - 1:4 1:3.9 - 1:2.1 1:2 - 1:0.590

10

20

30

40

50

60

7065%

34%

20%Mo

rta

lity

%

n=31 n=56n=165

Variable Low ratioFFP:RBC

1:8 (0:22 – 1:4)

Medium ratioFFP:RBC

1:2.6 (1:3.9 – 1:2.1)

High ratio FFP:RBC

1:1.4 (1:2 – 1:0.6)

p value

ISS 18 (16-25) 18 (14-25) 18 (16-25) 0.83

%ISS >25 23 20 22 0.94

FFP:RBC ratio

Data: median (IQR)

Borgman, MA, Spinella, PC, et al. “Ratio of blood products affects mortality in trauma,”J Trauma 2007:63(4); 805-813

20%

34%

65%

0

10

20

30

40

50

60

70

0:22 - 1:4 1:3.9 - 1:2.1 1:2 - 1:0.59

Mo

rta

lity

%

n=31n=56 n=165

Variables upon admission

Low ratio FFP:RBC

1:8 (0:22 – 1:4)

Medium ratio FFP:RBC

1:2.6 (1:3.9 – 1:2.1)

High ratioFFP:RBC

1:1.4 (1:2 – 1:0.59) P-value

INR 1.78 (1.00-2.86) 1.54 (1.30-2.10) 1.54 (1.30-2.19)   0.86

Hgb 9.4 (7.1-10.9) 10.8(8.5-12.6) 10.9(9-13.1) 0.01

Plt level 225 (132-275) 177 (128-241) 216 (150-277) 0.79

Base Deficit 13 (4-14) 8 (3-14) 8 (4-13) 0.39

Temp 97 (94.9-97.6) 96.5 (94.2-98.0) 96.0 (94.0-97.5) 0.14

HR 122 (97-149) 117 (103-133) 112 (92-129)   0.08

Data: median (IQR)

Cause of death by ratio group

1

2

6

2

6

1

2.5

7

0.51

0102030405060708090

100

0:22 - 1:4 1:3.9 - 1:2.1 1:2 - 1:0.59

Hemorrhage

Sepsis

MOF

Airw ay/Breathing

CNS

95%

70%

39%

Mo

rta

lity

%

Borgman, MA, Spinella, PC, et al. “Ratio of blood products affects mortality in trauma,”J Trauma 2007:63(4); 805-813

Multivariate for Survival

Applying Hemostatic Resuscitation

Must identify who is at risk EARLY Death from hemorrhage typically occurs in the

first 6 hours Applying hemostatic resuscitation liberally

places patients at unnecessary risk for multiorgan failure, respiratory compromise, and thromboembolic events

Several predictive scores TASH score ABC score

TASH: Trauma-associated Severe Hemorrhage Score

Systolic blood pressure (<100 mm Hg=4 pts, <120 mm Hg=1 pt)

Hemoglobin (<7 g/dL=8 pts, <9 g/dL=6 pts, <10 g/dL=4 pts, <11 g/dL=3 pts, and <12 g/dL=2 pts)

Intra-abdominal fluid (3 pts) Complex long bone and/or pelvic fractures (AIS

3/4=3 pts and AIS 5=6 pts) Heart rate (>120=2 pts) Base excess (<-10 mmol/L=4 pts, <-6 mmol/L=3 pts,

and <-2 mmol/L=1 pt), Gender (male=1 pt).

Mortality based on TASH score

0

10

20

30

40

50

60M

ort

ali

ty

High RatioLow Ratio

% MT <10 10-15 16-25 26-39 40-54 >54

TASH score 0-8 9-10 11-12 13-14 15-16 >16

High ratio (n) 432 167 182 144 134 288

Low ratio (n) 492 152 144 102 77 160

p value * n.s. n.s. n.s. n.s. 0.009 0.025 Borgman, MAUnpublished data

TASH: Trauma-associated Severe Hemorrhage Score

Potential Plasma Mechanisms

Activates human endothelial cell kinase pathways Protective for endothelial cell injury

Restores endothelial glycocalyx Needed for cell integrity and function

Decreased pulmonary and lymphatic endothelial cell permeability

Increased Syndecan-1 expression Endothelial cell glycocalyx membrane protein involved

in cell function and integrity

JB Holcomb. Presented at 2009 Shock Society Conference

Apheresis Platelets

Evaluated 462 casualties in Iraq who received a massive transfusion

Three groups based on aPLT:RBC ratio >1:16, 1:8-16, <1:8

Evaluated 24hr, 30 day survival

Perkins, JG, Cap, AP, Spinella, PC, et al. “Evaluation of the impact of Apheresis Platelets.” J Trauma. 2009; 66: S77-S85

Mortality at 30 daysCox Hazard Regression

Variable Hazard Ratio p Value ISS 1.06 <0.001 INR 1.16 0.03 Plasma Ratio 0.98 0.01 aPLT ratio 0.91 <0.001 Base deficit 1.04 0.07 Stored RBC units 1.03 0.08

Perkins, JG, Cap, AP, Spinella, PC, et al. “Evaluation of the impact of Apheresis Platelets.” J Trauma. 2009; 66: S77-S85

Survival to 24hrs and 30 days

Perkins, JG, Cap, AP, Spinella, PC, et al. “Evaluation of the impact of Apheresis Platelets.” J Trauma. 2009; 66: S77-S85

Warm Fresh Whole Blood

Spinella, PC, Perkins, JG, et al “Association of Warm Fresh Whole Blood with Survival”J Trauma. 2009; 66;S69-S76

Retrospective, 354 pts transfused ≥1U of RBCs Compared patients transfused

Fresh Whole Blood + (PRBC, FFP) Stored components (PRBC, FFP, aPLTs)

Groups compared equal in: Age, severity of injury Admission vital signs and labs, RBC amount Average patient was in hemorrhagic shock Base deficit of 6 and INR of 1.4

Variable WFWB (n=100) CT (n=254) P value

Total RBC (U) 16 (11-22) 16 (10-22) 0.44

Anticoagulant / Additives (L)

2.1 (1.5 – 3.1) 3.3 (2.1 – 4.6) <0.001

Results

Days30.0025.0020.0015.0010.005.000.00

Surv

ival

1.0

0.9

0.8

0.7

0.6

0.5

Kaplan Meier Curve of 30 day survival

WFWB group

CT group

Log rank test, p= 0.002

Warm Fresh Whole Blood

Component Therapy

Variables OR (95.% C.I.) P value

WFWB group* 15.4 (2.3 – 106) 0.005

Plasma:RBC ratio 10.3 (2.3 - 45.) 0.002

ISS 0.94 (0.91 - 0.97) 0.001

GCS eyes (normal) 3.91 (1.5 - 10.4) 0.006

Base deficit 0.88 (0.82 – 0.95) < 0.001

Multi-variate Logistic Regression for 30 day survival – Patient study groups

* Reference group were CT patients AUC (95% CI) = 0.9 (0.85-0.95)

Discussion

Potential mechanisms for WFWB association with improved survival Improved function of RBCs, plasma, platelets in

WFWB Thoroughly documented - Increased storage time for all

blood products leads to decreased function 1-4

WFWB use minimizes use of old RBCs Old RBCs: hyperinflammatory, immunomodulatory, impair

vasoregulation, poor O2 delivery Increased anti-coagulants and preservatives in stored

components1 Spinella PC, Crit Care Med, 20072 Napolitano LM, Crit Care Clinics, 20043 Lavee J, J Thor Cardiov Surg, 19894 Mohr R, J Thor Cardiov Surg, 1988

Discussion

WFWB patients - Increased incidence of Renal failure ARDS, DVT – approached significance

Since survival increased in WFWB group May be result of these patients living long enough

to develop these complications

Univariate analysis only and not adjusted with multivariate analysis

Component Therapy vs Fresh Whole Blood

PRBCHct 55%335 mL

Plt5.5x1010

50 mL

FFP80%

275 mL

So Component Therapy Gives You1U PRBC + 1U PLT + 1U FFP + 10 pk Cryo = 660 COLD mL

•Hct 29%•Plt 87K•Coag activity 65%•750 mg fibrinogen

500 mL Warm

Hct: 38-50%

Plt: 150-400K

Coags: 100%

• Armand & Hess, Transfusion Med. Rev., 2003

1500 mg Fibrinogen

1500 mg Fibrinogen

German Trauma Study 713 patients transfused >10 units Divided into 3 RBC:FFP ratio groups:

<0.9, 0.9 – 1.1, >1.1 Excluded deaths in the ED

Minimizes survivorship bias Counted transfusions in ED and OR (not ICU)

Average 4 hours Minimizes catch-up bias

Maegele, M. et al. “Red blood cell to plasma ratios transfused during massive transfusion are associated with mortality in severe multiply injury.” Vox Sanguinis, 2008.

German Trauma StudyRBC:FFP ratio mortality

>1.1

0.9-1.1

<0.9 (more FFP)

Massive Transfusion Protocol

Implemented “trauma exsanguination protocol”

Before/after cohort study 10 pRBC + 6 FFP + 2 PLT

Then 6 pRBC + 4 FFP + 2 PLT

Mortality 65.8% to 51.1% Showed decreased RBC and FFP and PLT

utilization

Cotton, et al. “Damage Control Hematology” J Trauma May 2008

Decreased utilization of blood products

Current Army Policy

Transfuse to a ratio of 1:1:1 of FFP:RBC:PLT for those patients presenting with severe life threatening trauma/hemorrhage at risk for massive transfusion

Use of fresh whole blood is authorized for patients with life-threatening injuries (at discretion of MD)

Current MT PolicyUS Army

RBC:FFP1:1

RBC:FFP:PLT1:1:1

rFVIIarFVIIa

In military casualties requiring massive transfusion, early administration of rFVIIa decreased pRBC use by 23%

rFVIIa increases the SBP at which arterial rebleeding occurs

suggesting the formation of a tighter, stronger fibrin plug in the presence of high concentrations of rFVIIa

Seven prospective, randomized surgical trials have documented the safety of this drug.

The clinical goal is a subnormal PT or INR, ensuring that if bleeding is still occurring then surgical intervention is required.

In military casualties requiring massive transfusion, early administration of rFVIIa decreased pRBC use by 23%

rFVIIa increases the SBP at which arterial rebleeding occurs

suggesting the formation of a tighter, stronger fibrin plug in the presence of high concentrations of rFVIIa

Seven prospective, randomized surgical trials have documented the safety of this drug.

The clinical goal is a subnormal PT or INR, ensuring that if bleeding is still occurring then surgical intervention is required.

When comparing rFVIIa (+) to rFVIIa (-) patients 24 hour mortality was 7/49 (14%) and 26/75 (35%), (p=0.01)

30 day mortality was 15/49 (31%) and 38/75 (51%), (p=.03).

SBP was higher in the rFVIIa (+) group

The use of rFVIIa was associated with improved early and late survival after severe trauma and massive transfusion.

rFVIIa was not associated with increased risk of thrombotic events.

The Effect of Recombinant Activated Factor VII on Mortality in Combat-Related Casualties With Severe Trauma and Massive TransfusionPhilip C. Spinella, MD, Jeremy G. Perkins, MD, Daniel F. McLaughlin, MD, Sarah E. Niles, MD, MPH,Kurt W. Grathwohl, MD, Alec C. Beekley, MD, Jose Salinas, PhD, Sumeru Mehta, MD, Charles E. Wade, PhD,and John B. Holcomb, MD J of Trauma- Feb 2008

Retrospective Study of Combat Casualties Who did and did not Receive rFVIIa

Jan 2004 - Oct 2006 n = 615

Retrospective Study of Combat Casualties Who did and did not Receive rFVIIa

Jan 2004 - Oct 2006 n = 615

329 US casualties did not receive rFVIIa

ISS = 21 ± 14 Complications = 17%

Thrombotic = 11% ICU days = 6 ± 24 Hospital days = 27 ± 40 PRBCs = 8 ± 7 Mortality = 19%

286 US Casualties did receive rFVIIa

ISS = 24 ± 13* Complications = 23%*

Thrombotic = 14% ICU days = 10 ± 15* Hospital days = 37 ± 35* PRBCs = 18 ± 22* Mortality = 21%

* P < 0.05

Once administered check:FBC, Clotting, fibrinogen and ABG

RE-ASSESSMENTABCDE

If haemorrhage continue

Activate MMT PACK 2Please, specify location of

patient

MMT PACK 2

HAEMOSTASIS

HAEMORRHAGE CONTROL:SurgeryStabilize fracturesPelvic brace

PREVENT HYPOTHERMIA

HAEMOSTATIC DRUGS:Consider the following if bleeding persist despite surgical interventions:Activated factor VII Beriplex (consider when patient who is on anti-coagulant) Antifibrinolitic agentsPlease discuss any of these therapeutic measures with Haematologist on call)

INTRA-OPERATIVE CELL SALVAGE:Transfuse 1 x FFP every 250 ml of bloodTransfuse 1 x ATD platelets every 1000 ml of blood

2 x packs of Cryoprecipitate if Fibrinogen is < 1.0 g/l

Fail to reach targets

MANAGEMENT of MASSIVE TRANSFUSION (MMT) for TRAUMA

4 X RBC4 X FFP

1 X ATD Platelets

MMT ACTIVATION For Trauma

PATIENT ARRIVALTake bloods (FBC, U&E, Clotting, fibrinogen and X-match and ABG)Send pink bottle with X-match form to blood bank urgently ( please obtain 2 samples for x-match at different time if possible)

MMT PACK 1 4 x O –ve RBC ( female) or O+ve(Male) 4 x AB FFP

(or Group specific if possible)

THERAPY TARGET end point:

Hb: 8-10 g/dlPlatelets > 100PT&APTT (INR)< 1.5Fibrinogen > 1.0 g/lCa² > 1 mmol/l⁺pH: 7.35-7.45BE: ± 2Tª > 36 °C

Pre-hospital MMT alert:

• Systolic BP < 90• Poor response to

initial fluid resuscitation

• Suspected active haemorrhage

If so activate MMT (match 3 of the ocriteria)

Hospital MMT alert confirmation(patient requiring urgent transfusion)

- SBP < 90- HR > 100- Ph < 7.35- BE < - 2- Obvious signs of uncontrollable active bleeding- Poor responder to fluid resuscitation

(Trauma Team leader must declare MMT Activation to blood bank ,WHH Bleep no:8662)

Co-ordinate Porter urgently to standby for Collection of MMT pack one

When MMT stopsNotify blood bank Return any unused products Resume standard ordering practices

PREVENT

HYPOTHERMI A

AC I DOS I S

COAGULOPATHY

Once administered check:FBC, Clotting, fibrinogen and ABG

RE-ASSESSMENTABCDE

If haemorrhage continue

Activate MMT PACK 2Please, specify location of

patient

MMT PACK 2

HAEMOSTASIS

HAEMORRHAGE CONTROL:SurgeryStabilize fracturesPelvic brace

PREVENT HYPOTHERMIA

HAEMOSTATIC DRUGS:Consider the following if bleeding persist despite surgical interventions:Activated factor VII Beriplex (consider when patient who is on anti-coagulant) Antifibrinolitic agentsPlease discuss any of these therapeutic measures with Haematologist on call)

INTRA-OPERATIVE CELL SALVAGE:Transfuse 1 x FFP every 250 ml of bloodTransfuse 1 x ATD platelets every 1000 ml of blood

2 x packs of Cryoprecipitate if Fibrinogen is < 1.0 g/l

Fail to reach targets

MANAGEMENT of MASSIVE TRANSFUSION (MMT) for TRAUMA

4 X RBC4 X FFP

1 X ATD Platelets

MMT ACTIVATION For Trauma

PATIENT ARRIVALTake bloods (FBC, U&E, Clotting, fibrinogen and X-match and ABG)Send pink bottle with X-match form to blood bank urgently ( please obtain 2 samples for x-match at different time if possible)

MMT PACK 1 4 x O –ve RBC ( female) or O+ve(Male) 4 x AB FFP

(or Group specific if possible)

THERAPY TARGET end point:

Hb: 8-10 g/dlPlatelets > 100PT&APTT (INR)< 1.5Fibrinogen > 1.0 g/lCa² > 1 mmol/l⁺pH: 7.35-7.45BE: ± 2Tª > 36 °C

Pre-hospital MMT alert:

• Systolic BP < 90• Poor response to

initial fluid resuscitation

• Suspected active haemorrhage

If so activate MMT (match 3 of the ocriteria)

Hospital MMT alert confirmation(patient requiring urgent transfusion)

- SBP < 90- HR > 100- Ph < 7.35- BE < - 2- Obvious signs of uncontrollable active bleeding- Poor responder to fluid resuscitation

(Trauma Team leader must declare MMT Activation to blood bank ,WHH Bleep no:8662)

Co-ordinate Porter urgently to standby for Collection of MMT pack one

When MMT stopsNotify blood bank Return any unused products Resume standard ordering practices

PREVENT

HYPOTHERMI A

AC I DOS I S

COAGULOPATHY

SummarySummary

Early Dx in ED

Warm Fresh Whole Blood (WFB)

1:1:1 ratio of Plasma: RBC: PLT

Aggressive use of cryo and platelets

ED use of rFVIIa and repeated doses in OR and ICU as required

Limit excessive use of RBCs & crystalloids

Use RBCs of decreased storage age