Clinical Case 031: Big transfusion, Little Hospital = big trouble
I have been working on a post dealing with massive transfusion – Broome style – for a while now. So last week we landed in a tricky situation. My colleague had taken a chap with a splenic rupture to theatre and used a good volume or red cells – depleting our small blood bank, when we received another incoming trauma case! So I thought this case was a good one to illustrate the “Stripped back” approach to massive transfusion / trauma resuscitation as I see it in smaller hospitals with limited agents.
Here is the Case:
40 yo man with major crush injury. The chap’s abdomen was trapped for about ten minutes until the load could be moved. Remained conscious throughout this period. Ambos bundled him into ED within 10 minutes and he arrived… then had a PEA (likely combo of hypovolemia and severe acidosis) arrest. CPR and IV adrenaline en route to OT. Regained consciousness as the ETT went down (doh). Anaesthetised and prepped for laparotomy. Initial ABG came back showing a lactate of 15! pH = 6.8.
Laparotomy showed a bunch of sub-segmental mesenteric vein ruptures, a big rectus haematoma with a few litres of red in the peritoneum. The lab called to say – only 4 bags of FFP left, more PRBCs coming in by plane from elsewhere…
So – how to proceed? Lets keep this big picture – what strategies do we want to use for:
(1) Anaesthesia / analgesia
(2) Fluid resuscitation – what type, how much? targets?
(3) How do we monitor / measure if we are winning? What is useful?
(4) Surgeon – what should they do? When?
(5) This chap developed quite good going “ACoTS” – what agents / strategy should we use to treat this?
I hope to do a post soon looking at the new guidelines released in 2010 and strip them down to make them usable in the smaller hospitals where blood doesn’t grow on trees and budgets are non-existent. Watch this space….
So all you experts – what gives us bang for our buck, what can we store for a while and what is just hard / expensive for a small hospital. Better still – what is cheap and easy, available and going to make a difference to patients like this?
Casey
If I was optimizing a massive transfusion protocol for a smaller hospital, here is what I would be considering:
Stock prothrombin complex concentrate, at least 5 or 6 boxes available at all times. No need to type, long time till expiration, and has effects instantly
Stock fibrinogen concentrate. More important than platelets in early ACoTS, long lasting stable and no need to type.
This will get you through the first 90-minutes along with a bunch of O neg. Your blood bank is going to need to put out a call for extra ffp/plt/cryo.
That’s where the small hospital differences end, everything else is the same everywhere
Infuse everything through a warmer, plenty of CaCl.
Accept low BPs if it means avoiding any vasopressors. Poor perfusion is what is causing upregulation of coagulopathy.
Keep initial op to <90 min, preferably 50 with a completely sympatholysed patient, urine starts, oozing stops
Hi Casey
I wrote a prehospital protocol for Tranexamic acid in haemorrhagic shock patients recently.
Its cheap, level 1 evidence based and safe. The loading dose costs around $57.
I think every rural hospital should have it.
There is an ongoing RCT called WOMAN trial looking at its use in PPH just to let you know. In other words its got potentially dual indications for the bleeding patient.
Whatever happened to the emergency donor panels so common in the past in rural areas? Seemed to have gone out of fashion but probably the only practical strategy in rural and remote areas. You work in low resource developing nation settings or conflict zones, fresh donors are the only way to give emergency blood transfusions.
I am O +ve and try to donate blood every 3 months to ensure I know I am getting regularly screened. the nice way to do it is use a blood donation kit..you get these from the blood bank or lab..they use them all the time for venesection therapy patients or of course to take blood for donation…and its like giving a blood donation.
I know one unit of whole fresh blood might not be enough but I figure if its some kid bleeding to death with a ruptured spleen or something like that then one unit from me might make a difference..or at least I want to believe that! It might pay to talk to your local staff and see who might be willing in a dire emergency to donate fresh blood.
Some may balk at this but it was and still is common practice around the world..not so much here in Australia anymore…I guess because our retrieval services have become so good!
I know that they used to have living donors where I work (Kangaroo Island) but dunno how long it has been since last used. I wonder if it would even be allowed in today’s medicolegal climate. That said, we only have two units of O neg, then we’re out.
I guess if we were weathered in, and used up our packed calls, then I’d be faced with no choice but to use living donor if a life or death scenario (and presuming could counsel recipient re risk of BBVs and transfusion reaction etc)
Would anyone else?
Meanwhile, I’m hoping to get TXA[tranexamic acid] in soon, as despite the CRASH-II trial detractors, it’s cheap as chips and seems to confer a survival advantage if give early enough. Interested to see your protocol Minh if you care to share…
Anyway, in terms of answering Casey’s questions
1- give a high opiate anesthetic. Sounds like Casey incubated him cold [actually I came in late on this one Tim] – I would have worried about giving sux[suxamethonium] in context of crush injury, but he’s already arrested from his hypoxia/hypovolaemia and possible bilateral tPTXs. Did anyone do bilateral finger thoracostomies as he was PEA? [the crush was well below his costal margins – so no, not done]
– in terms of fluid, aliquots of Hartmans titrated to radial pulse, permissive hypotension, accept SBP 70-80 mmHg
– measure progress by response to fluid aliquots (if he’s got a radial pulse, I am happy). hR, SBP, urine output and if possible measure serum lactate and base excess. Talking of which, he may need bicarbonate given his crush injury. How’s his potassium?
– what should surgeon do? Depends on his/her capabilities and institution capabilities. I hear more blood products are on their way, but it may be a case of packing bleeding points, and shipping out for definitive care somewhere bright and shiny (tertiary centre) ie damage control surgery.
– in terms of ACOTs, prevention better than cure – treat acidosis, hypothermia and coagulopathy. tranexamic acid given early. I reckon fresh whole warm blood would be best….but unless in war zone with military resources, he’s gonna get packed cells, FFP, platelets and cryo. Not sure nova seven will make much difference (and we don’t have it). So tive TXA and ideally a 1:1:1 ratio of blood products, although there are no RCTs demonstrating an advantage and the military data may be skewed through survivor bias in this case.
It’s all a bit voodoo, isn’t it?