The problem with most “massive transfusion protocols” – they don’t specify who is likely to benefit, whom should activate it and upon which patient. Most of the identifiers of Massive transfusion say things like “after 6 units in 4 hours” or “after a whole blood volume equivalent”, the problem being it might be a bit late to correct some of the pathophysiology – it is better to anticipate and activate, rather than wait and see.
A: Use a clinical prediction rule to stratify the need for MTP:
The ABC score: 4 points = penetrating injury, positive FAST exam, HR > 120/min, systolic BP < 90 [no lab results – purely clinical]
These systems allow you to ‘triage’ the patient and anticipate the probability of needing a massive transfusion. Why is this important? Well – giving all that blood, plasma and factors to the patient who didn’t need it has serious consequences – namely a risk of sepsis, ARDS and organ dysfunction – Inaba et al showed the main villain was the plasma volume trasfused. So MTP is good if you need it, but might be bad if you were not needing it – so we need to exercise some restraint.
STEP 3:Activate Hospital Massive Transfusion system
Lab team need to know early – they will need to prep products and process your incoming blood samples AQAP
Early thawing of 2 units FFP if large volumes are expected.
Dedicated nurse / team member to run the rapid infusion device
Orderly to run samples and bloods to the lab for processing
Scribe to document the products / volumes and response
Maintain patient T > 35 deg IV fluid warmer, airblanket, limit exposure & operation time
**The use of recomb. factor VII (NovoSeven) remains controversial – this should only be used in consultation with Haematologist and once other reversible causes of coagulopathy have been addressed / targets reached
STEP 8: Evacuation planning
In smaller centres the early evacuation planning should commence as soon as the patient is received
In the absence of a definitive surgical service – evacuation should be expediated to such a centre
The retrieval team should be made aware of the product availability and stock so they can plan to bring further agents for the ongoing resuscitation / transfer.
Suggest early liason with RFDS, receiving hospital ED / surgeon and clinical Haematologist