Giving blood in trauma- It’s not that

simple!Andrew J. Kerwin, MD, FACS

University of Florida Department of SurgeryUF Health Jacksonville, Trauma Medical Director

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

Trauma Center Vital Signs

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Trauma Center Vital Signs

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Binder

Does this patient exhibit signs of

bleeding?

4 Classes of Hemorrhagic Shock

Large Bleeding Producing Shock

Large bleeding producing shock

How do we resuscitate this

patient?

What are the Consequences?

“Pop the clot” Uncontrolled hemorrhage Capillary leak Multiple negative systemic effects

AGGRESSIVE CRYSTALLOID RESUSCITATION

Consequences

Crystalloid causes severe resuscitation injury!

Consequences of uncontrolled hemorrhage

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

How do we manage the bleeding?

Coagulation Cascade

This is simple?

Simple: Damage Control Resuscitation

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)

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

Why develop a MTP?

Advantages• Rapid supply • Sustained supply• Improves mortality

Disadvantages• Time consuming

effort• Wastage• Confusion

• Ratio?• Batch content?• Batch size? • Trigger?

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

Traumatic Coagulopathy

Simmons JW & Powell MF. Br J Anesth.2016

Who should develop a MTP?Multidisciplinary collaboration of:

Trauma surgeons Emergency Medicine Anesthesiology Pathology Transfusion services Blood bank Nursing

When should we activate the MTP?

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

When should we activate MTP?

Camazine MN, et al. J Trauma. 2015Cantle PM, Cotton BA Crit Care Clinics 2017

ABC score is a simple trigger for MTP

How much blood should we transfuse?

Why 1:1:1 ratio?

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

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

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

Glaser J, et al. J Trauma. 2015

What about adjuncts to MTP?

Storage and Transportation

Fibrinolysis

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

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