Transcript
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!
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