Massive transfusion in trauma. Dr Anne Weaver Consultant in Emergency Medicine & Pre-Hospital Care Royal London Hospital
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1 Massive transfusion in trauma Dr Anne Weaver Consultant in Emergency Medicine & Pre-Hospital Care Royal London Hospital
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4 Transfusion in Trauma 40% trauma deaths attributed to uncontrolled haemorrhage Up to 55% trauma patients are coagulopathic on arrival at hospital 9% require transfusion 3% require massive transfusion Massive transfusion carries mortality 30-60%
5 Mortality (%) 60% 40% 20% 0% PRBCs in 24 Hours
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8 Definition - Massive Transfusion Replacement of one blood volume in 24 hours Transfusion of >10 u RBC in 24 hours Loss of 50% of blood volume in 3 hours Loss of >150ml / minute Requirement to transfuse 4 u RBC immediately with ongoing losses
9 Aims Define massive transfusion Describe importance of MT protocols Describe acute traumatic coagulopathy Share some research findings Challenge your current transfusion practice
10 Massive Transfusion in Trauma Baltimore study 5643 patients 68 patients received >20 u RBC (1.2%) Massive transfusion group 50% mortality Massive transfusion group used 50% of blood products for centre Average age of survivors - 35yrs
11 Role of MT protocol No difference in ISS for survivors vs non-survivors Vascular control is key to survival an intact coagulation system contributes to haemorrhage control, protocols that minimise coagulopathy should reduce blood usage and improve survival
12 Audit of MTP - Denmark Established MT protocol 39 patients received MT 13 inadequately transfused Higher mortality (12/13 vs 13/26) Higher rate of microvascular bleeding Lower platelet count on ICU (40 vs 80) Violations 1) >20PRBC but no FFP 2) no platelets despite mean 67u PRBC / FFP Same RBC requirements but different outcome if not given FFP and platelets Vox Sanguinis 2005;89:92-96
13 Transfusion issues in ED Prehospital / ED crystalloid Uncrossmatched O blood packed cells Delay in plasma availability Blood typing / thawing Uncertainty as to which products needed Traditional transfusion guidelines Delay for lab results
14 Modern transfusion medicine Preparation of blood components means not as efficacious as the real thing! PRBC do not contain any clotting factors Must replace with FFP early After 12 u PRBC - PT > 1.5 x normal (100%) Replacement of total blood volume causes thrombocytopenia Relatively late due to release from sequestration Worse outcome if thrombocytopaenic Acute bleeding plt > 50 x 10 9 Massive transfusion - plt > 80 x 10 9
15 Blood products PRBC FFP clotting factors & fibrinogen Platelets pooled (ATD) or single units Cryoprecipitate Factor VIII, XIII, vwf, fibrinogen Some protocols consider rfviia
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17 ED INR: 1.8 ICU INR: 1.6
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19 Acute Traumatic Coagulopathy ATC
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21 No difference in volume of fluid given 24% patients were coagulopathic on arrival in ED
22 Mortality normal: 11% coagulopathic: 46%
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33 Stab Popliteal Artery ISS: 6 BD: 13
34 Stab Popliteal Artery ISS: 6 BD: 13 Pelvic fracture ISS: 41 BD: 4
35 Stab Popliteal Artery ISS: 6 BD: 13 Pelvic fracture, Shocked ISS: 50 BD: 15 Pelvic fracture ISS: 41 BD: 4
36 Stab Popliteal Artery ISS: 6 BD: 13 PT: 13 APTT: 23 Pelvic fracture, Shocked ISS: 50 BD: 15 PT: 18 APTT: 46 Pelvic fracture ISS: 41 BD: 4 PT: 12 APTT: 23
37 Stab Popliteal Artery ISS: 6 BD: 13 PT: 13 APTT: 23 Fib: 2.3 Plt: 272 Pelvic fracture, Shocked ISS: 50 BD: 15 PT: 18 APTT: 46 Fib: 1.8 Plt: 140 Pelvic fracture ISS: 41 BD: 4 PT: 12 APTT: 23 Fib: 2.8 Plt: 232
38 Pelvic fracture ISS: 41 BD: 4 PT: 12 APTT: 23 Fib: 2.8 Plt: 232 Pelvic #, Shocked ISS: 50 BD: 15 PT: 18 APTT: 46 Fib: 1.8 Plt: 140 Stab Pop Artery ISS: 6 BD: 13 PT: 13 APTT: 23 Fib: 2.3 Plt: 272
39 Pelvic fracture ISS: 41 BD: 4 PT: 12 APTT: 23 Fib: 2.8 Plt: 232 Pelvic #, shocked ISS: 50 BD: 15 PT: 18 APTT: 46 Fib: 1.8 Plt: 140 Stab Pop artery ISS: 6 BD: 13 PT: 13 APTT: 23 Fib: 2.3 Plt: 272
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42 Consumption Acidemia Hypothermia Dilution
43 Consumption Acidemia Hypothermia Dilution
44 Hypoperfusion
45 XIIa XIa platelet + VIIa IXa Xa - - Thromb in + Fibri n apc PC Thrombin-TM TM TM TM TM
46 Trauma Shock ATC Haemorrhage COAGULOPATHY
47 Trauma Shock ATC Haemorrhage Fibrinolysis Inflammation Genetics Hypothermia Acidaemia Loss, Dilution COAGULOPATHY
48 How do you diagnose ATC?
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50 PT & PTT
51 PT & PTT
52 Can we predict ATC / MT?
53 Prehospital / admission physiology?
54 Early predictors for transfusion hypothermia, acidosis, coagulopathy ISS > 25 ph < 7.1 / Base deficit >6 / Lactate Temp < 35 o C Physiological parameters SBP<90, HR >120, GCS<9 PT / APTT >1.5x normal Trauma Associated Severe Haemorrhage Score (TASH) J Trauma 2006;60: Emergency Room Transfusion Score (ETS) Transfusion Medicine 2006;16:49-56
55 Near patient testing?
56 Pelvic fracture ISS: 41 BD: 4 PT: 12 APTT: 23 Fib: 2.8 Plt: 232 Pelvic #, Shocked ISS: 50 BD: 15 PT: 18 APTT: 46 Fib: 1.8 Plt: 140 Stab Pop artery ISS: 6 BD: 13 PT: 13 APTT: 23 Fib: 2.3 Plt: 272
57 EXTEM CA (mm) PT>12.6 PT<=12.6 A5 A10 A15 A20 A25 A30 Time (minutes)
58 ATC: 5 minute Clot Amplitude < 37mm
59 CA5 <37mm (poor clot): 4 vs 1 units PRBCs 37% vs 5% required FFP 80% sensitivity for >10 units PRBC
60 CA5 >37mm (good clot): 88% NPV any PRBC 95% NPV 6+ PRBC 99% NPV 10+ PRBC
61 What do the curves mean? Can ROTEM/TEG guide therapy?
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63 FFP:PRBC ratio
64 1:2 / 2:3 / 1:1
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66 RLH Protocol 2004 General common sense approach Initial clinical trigger Hourly investigations 3 FFP, 5 cryo, 1 ATD platelets Keep plt >80 Platelet function / Head injury Consider rviia
67 Potential benefits of MT protocol Recognise that traditional guidelines based on observation / expert opinion Acknowledge early administration of products is beneficial Better communication with lab Reduce inappropriate blood product use Improve haemostasis Improve outcome - survival
68 Potentially fatal errors Blood, blood, blood Over transfusion Hyperkalaemia Hypocalcaemia Hypothermia Transfusion errors legal requirements
69 Massive Haemorrhage Protocols
70 Code Red - RLH Blood in resus after 2 SUIs Need for escalated response Collaborative pathway Evidence based to some extent Military unpublished work
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74 Code Red at RLH Jan 08 Oct HEMS pre-alert Median PRBC 8 units (0-45) Median FFP:PRBC ratio 0.45 Median ISS 29 Median BE -7.7 Median Hb 11.9 on arrival 75 survivors General trend to improved ratios
75 Summary Traumatic coagulopathy is commoner than we recognise Standard blood tests underestimate the problem Early blood product administration can improve survival Local protocols need careful implementation and training
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