Rachel HawesRVI

Northern trauma network conference

March 2014

Major Haemorrhage Policy for Trauma

Background

• Leading cause of traumatic death• Advances in haemostatic resuscitation• Balanced transfusion 1:1:1:1• Introduction of MHP

• Questions– How many major haemorrhage pt?– Frequency of Acute Coagulopathy of Trauma (ACoT)– How effective is our MHP?

RVI Major Haemorrhage Policy

• Standardise blood product use

• Reduce logistical delay

• Prehospital initiation • Pre-thawed FFP– avoid delay in receiving

balanced transfusion

Audit • Inclusions

– All trauma patients to RVI– April 2012 - April 2013– >18 yrs– Activation of MHP– Or >4 products in 1 hr

• Exclusions– Children– Preceding medical event– Transfers via Trauma Units

• Data Collection– Injury Severity Score (ISS)– TARN Predicted Survival– Actual 30 day mortality

– Presentation - Hb, PT, Fib– Products Transfused– Post MHP - Hb, PT, Fib

Results - How much trauma do we get?

• April 2012 - April 2013• 935 trauma calls• 899 TARN patients

– RTA– Assault– Fall

• Frequent of major haemorrhage?• 51 MHP Patients (5.6%)

Injury Severity Score v Mortality

Mortality - Standard Trauma Pt v MHP Pt

ISS versus Predicted & Actual Outcome

Coagulopathy

ACoT on Presentation in ED?

• Fibrinogen on presentation• Fibrinogen <1.5 = 21%

• PT on presentation• PT> 18 = 16%

Is ACoT due to Prehospital Fluid?

• No correlation between fluid volumes given and– Hb on presentation– PT on presentation– Fib on presentation

Presence of Coagulopathy Post MHP

• Post MHP Fib <1.5 = 0%• (Data for 33 Pt)

• Post MHP PT > 18 = 3%• (Data for 29 Pt)

Hb on Arrival v Post MHP

• Hb on arrival <8.0 = 6.8%

• Over and under transfusion

• Hb post MTP <8.0 = 5.8%

The Future

• Over and under transfusion– Deviation from policy– Timing of lab results– Lack of Point of Care testing - guide treatment

• Potential role of ROTEM/ TEG

• Prehospital Transfusion

Limitations

• Early deaths after presentation

• Unable to get bloods

• Included in ISS calculations but excluded for comparison of lab data

Summary• Trauma - Mortality proportional to ISS• 5% of patients have major haemorrhage• Increased mortality ass with major haemorrhage• 20% established ACoT on arrival

– Not related to prehospital fluid administration

• MHP effective in treatment and prevention of ACoT

• Future– POCT – TEG or ROTEM– ‘Blood on Board’ HEMS

Questions?