How would you reduce the red cell transfusion requirements in an actively bleeding multiple trauma patient?
Early recognition and identification of location of bleeding (0.5)
Early haemorrhage control with basic haemostatic measures including: (1)
-Use of staples for soft tissue bleeding e.g. scalp bleeding
-Use of tourniquets in traumatic amputations
-Avoiding scene delays
Early definitive haemorrhage control with surgery or angiographic techniques (0.5) Avoidance of excessive crystalloid infusion. (0.5)
“Permissive hypotension” is a fluid restriction strategy that limits dilutional coagulopathy, potentially limits clot dislodgement by maintaining a SBP 80-90mmHg.
Initial RCT single centre research (Bickel 1994 NEMJ) in penetrating torso injures showed mortality benefit in delayed fluid resuscitation. Further multi centre RCT research with blunt trauma confirmed the improved mortality in the permissive hypotension group.
The controversy exists in the presence of TBI (traumatic brain injury) and Spinal cord injury (SCI) and the avoidance of secondary brain injury. Brain trauma foundation guidelines aim for an SBP >90 or CPP > 60 to prevent this. Permissive hypotension is not suitable for these patients. There is no evidence for Hb level. The TRICC trial excluded these patients (1.5)
Avoid the lethal triad of hypothermia, acidosis, and coagulopathy.(0.5 mark each) Ensure an ionised Ca2+ > 1 mmol/l. (0.5)
Maintaining fibrinogen > 1.5 g/L. (0.5)
Maintaining platelets > 100 x 109 /L. (0.5)
Recognition of the presence of medications causing coagulopathy or platelet dysfunction such as aspirin, clopidogrel, warfarin or a novel oral anticoagulant. In this instance the provision of platelets, FFP or prothrombin concentrate complexes may be appropriate. (1)
Point of care testing such as thromboelastography to facilitate rapid and targeted coagulopathy correction. (1)
The use of tranexamic acid < 3 hours (CRASH2). (0.5) Appropriate cessation of the massive bleeding protocol. (0.5)
Prevent further haemoglobin loss:
Prevent wasteful use of blood products:
Tinmouth, Alan T., Lauralynn A. McIntyre, and Robert A. Fowler. "Blood conservation strategies to reduce the need for red blood cell transfusion in critically ill patients." Cmaj 178.1 (2008): 49-57.
Egea-Guerrero, J. J., et al. "Resuscitative goals and new strategies in severe trauma patient resuscitation." Medicina Intensiva (English Edition) 38.8 (2014): 502-512.
Tien, Homer, et al. "An approach to transfusion and hemorrhage in trauma: current perspectives on restrictive transfusion strategies." Canadian journal of surgery 50.3 (2007): 202.
Morrison, J. J., et al. "Intra‐operative correction of acidosis, coagulopathy and hypothermia in combat casualties with severe haemorrhagic shock." Anaesthesia 68.8 (2013): 846-850.
Duchesne, Juan C., et al. "Damage control resuscitation in combination with damage control laparotomy: a survival advantage." Journal of Trauma and Acute Care Surgery 69.1 (2010): 46-52.