Definition of Massive Transfusion

•Replacement of a blood volume equivalent within 24hr

•Transfusion>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

• hemodynamic stability• tissue oxygenation

packed red blood cells

• Each unit of (RBCs) contains approximately 200 mL of red cells

• in an adult, will raise the hematocrit by roughly 3 to 4 percentage points unless there is continued bleeding.

Dilutional coagulopathy

• happens with 5-10 or more RBC u.

platelet

• <50,000 with active bleeding and surgery, • (1 pack/10kg)( every unit of 50cc, increases

platelet up to 5000/ml), • no need for ABO compatibility but D Ag must

be compatible. • Each platelet concentrate also provides

around 50ml of fresh plasma.

Fresh Frozen Plasma• PT>16" or PTT>60”

• fibrinogen level is under 100 mg/dl;

• ( ABO matched)10-15 ml/kg . (250 cc/unit)

• needs 30 minute for defreezing.

Cryoprecipitate

• ( ABO matched) (1-1.5 packs/10kg)

• Hemophilia A, Von Willebrand, fibrinogen levels < 0.8g/l or decreased factor XIII

• 15cc/unit. 10u cryo (2 pack) results in fibrinogen>1gr/L

Recombinant FactorVIIα

• 90micgr/kg• Contrandicated: Plt<50000 Fibrinogen<1gr/L Abnormal PT Ph<7.2 BT<35

RBC:FFP

1:1RBC:FFP:PLT

1:1:1

RBC:FFP1:1

RBC:FFP:PLT1:1:1

Therapeutic goals

• Hemoglobin>8gr/dl• Platelet count>75,000• PT, aPTT<1.5× mean control• Fibrinogen> 1gr/l

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/lpH: 7.35-7.45BE: ± 2Tª > 36 °C

Pre-hospital MMT alert:

•Systolic BP < 90•Poor response to initial fluid resuscitation•Suspected active haemorrhageIf 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