MASSIVE TRANSFUSION in

traumaDr Gaynor Prince 2015

GOAL DIRECTED COAGULATION MANAGEMENT

Definition

Adults - replacement of >1 blood volume in 24 hours or >50% of blood volume in 4 hours

Children - transfusion of >40ml/kg

When should MTP be triggered?

Senior clinician - suspects impending or established hemorrhagic shock in a bleeding pt

Scoring systems

Thromboelastography

Assessment of Blood Consumption (ABC)

ScoreED SBP <90mmHg

ED HR >120bpm

Penetrating Mechanism

Positive FAST

3 = 45% chance MT

4 = 100% chance MT

TEG and ROTEM

A few things to know...

Viscoelastic haemostatic assay

measures - global visco-elastic properties of whole blood clot formation under low shear stress

What does this mean???

TEG and ROTEM

= interaction of platelets and the coagulation cascade

Assess the entire coagulation process - fibrin formation, clot - rate, strength, stability and lysis

Diagnose Trauma induced Coagulopathy (TIC)

Thromboelastogram

Use

prediction of need for transfusion

Guide transfusion strategy

trauma studies - reduction in blood product use and mortality

Availability

Red cell

O neg - immediate

ABO Group specific - 15 min

Crossmatched - 45 min

FFP - 30 min

Platelet - on site = immediate, otherwise hourly min

Actions

HISTORY

Age, Gender

MOI

Pre-hospital fluids/Blood Components

PMHx - coagulopathy

Meds - warfarin, clopidogrel, aspirin

Previous tranfusion rxn/antibodies

Actions

Control bleeding - early surgical involvementAVOID excess crystalloid useBloods -

CrossmatchABGFBC, U&E, CaCoag profile/ROTEM

Actions

Notify Transfusion Medicine UnitEXT 2783/PG 4415

Request Major Hmg Pack...

AVOID HYPOTHERMIA

!HYPOTHERMIA

!Fluid warmer - level 1Bair HuggerMinimise exposureMonitor Temperature

Ongoing Shock

Request more product & inform HaematologistPack A

1 unit adult platelets2 units RBC2 units FFP

Check results and repeat bloods - 30-60 min

Pack B- 2 Units RBC- 2 Units FFP

Blood Component Ratio Guideline

1:1:1

1 adult unit platelets = 4 units RBC = 4 units FFP

PROPPR trial - Pragmatic Randomised Optimal Platelet and Plasma Ratios Trial

OPTOMISE

Aims

Temp >35ºCpH >7.2Base Excess >-6Lactate <4Ca >1.1mmol/LPlatelets >50 x 109/L

PT/APTT < 1.5 normalINR <=1.5fibrinogen>1.0g/L

Adjuncts

Tranexamic acid - within first 3 hours of trauma ideally

1g over 10min then infusion 1g over 8 hours

CRASH 2 Trial - 2010

Adjuncts

Cryoprecipitate - if fibrinogen <1g/L or ROTEM indicates

NB in obstetric and trauma bleeds

1 dose cryo = 8 units

Ca Chloride 10ml 10% if Ca2+ <1.1mmol/L

Special Situations

Warfarin reversal

NOAC

Head Injury

Heparin reversal

rFVIIaRoutine use in trauma - NOT recommendedConsider use if

uncontrolled hmg in salvagable pt AND

failed surgical/radiological measures to control bleeding ANDadequate blood component replacement AND

Plt count >50pH >7.2Temp >34

Contact Haematologist

If in Doubt...

THANKS!