Massive Transfusion Protocol

MASSIVE TRANSFUSION PROTOCOL

STEP 1: Bleeding control

Control of bleeding is the single most important intervention.

• Minimise time between arrival and surgery if indicated – “Damage Control Surgery”
• This may require early Evacuation planning
• Use torniquets to control peripheral bleeding vessels
• Tamponade techniques: eg. pelvic binders, direct pressure, suture head lacs
• Intrauterine balloon devices for PPH, manual compression, oxytocic agents

STEP 2: Identify the  need for Massive Transfusion

Rationale (Click to expand)

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]
  • 0/4 = 1% risk of MTP,       1/4 = 10% risk,      2/4 = 41% risk,       3/4 = 48% risk,      4 /4= 100%  [Activate MTP if 3 + criteria met]
• The TASH score (diagram): 6 point scale = syst BP < 100,  HR > 120,   Hb < 70,   positive FAST,   femur or pelvic fracture,   base Excess <  -10,   INR > 1.5,   male gender

B:  Identify massive trauma / bleed on purely clinical basis – “the Crashing Patient” – this remains a subjective call based on a senior clinician’s suspicion of likely MTP requirement:

• Multitrauma with multiple system injuries and unstable haemodynamics
• Massive post-partum haemorrhage with measured blood loss > 1500 mls
• Post-surgical bleeding from major vessels
• GI bleeding with shock

Rationale for activation indications

 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

STEP 4: Initial Empirical Resuscitation (first 15 – 30 minutes)

Take bloods for URGENT processing: FBP, cross match, coag profile (INR, APTT, fibrinogen), ABG (VBG)

Request immediately available blood products.

1. Crystalloids – aim to minimise the use of crystalloids – they will make your coagulopathy, temp and possibly acidosis worse
2. Uncrossmatched (O Rh -) packed red cells – 2 units
3. Fresh frozen plasma (ABO Rh spec) – 2 bags.   [recommend 1:1 ratio where possible]  NOTE: thawing FFP takes ~ 30 minutes – so you need to alert the lab to this possibility early

STEP 5:  Continue Volume Resuscitation / Monitoring

A:  Continue  PRBCs and FFP in 1:1 ratio – target MAP is 65 – 70 mmHg (prior to definitive intervention)  NB:  target MAP is 90 – 100 in patients with traumatic brain injury / raised ICP suspected

B :  Monitoring – establish early and use to titrate specific agents / interventions

• Recommend invasive monitoring (arterial line) if available
• Send repeat investigations every ~ 30 minutes: FBP, coags, fibrinogen, ABG / lactate, Ca++,
• Frequent / continuous temperature monitoring

STEP 6:  Consider other agents for prevention / limitation of coagulopathy

• Warfarinised / known coagulopathy : give Vit K 10 mg,  Prothrombinex (25 iu/kg = ~ 4 vials for 80 kg pt)
• Dabigatran / thrombin inhibitor: call Haematology.  PCC and recomb. factor VII have some evidence in healthy subjects
• Obstetric haemorrhage: early use of cryoprecipitate is recommended (Reference 1,   Reference 2)
• Platelets: only recommended in thrombocytopenia < 50.  (Notify incoming team if required)
• Discuss specific clinical scenarios with on-call Haematologist
• Tranexamic acid:  give 1 g loading dose (over 10 mins)  as early as possible in traumatic bleeding

 STEP 7:Target therapy to results / clinical parameters

• Target BP – MAP = 65 mmHg                           Give fluid volume:  ideally RBCs / FFP
• IF Hb <  80 g/l                                                       THEN  Give RBCs
• if  INR > 1.5  OR  APPT > 50 sec                      Give 2u FFP  consider Prothrombinex
• if fibrinogen < 1.0 g/l                                          Give 8 units of cryoprecipitate
• if ion. Calcium  is < 1.1 mmol                            Give 1 amp of  Ca-gluc 1g/10mls
• Optimise acidosis                                                  Consider intubation / ventilation => normocapnea
• 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