Giving Blood in Trauma: Andy Kerwin, MD
Transcript of Giving Blood in Trauma: Andy Kerwin, MD
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