Transfusion Management of Massive Trauma Haemorrhage

Question 1

When should the massive haemorrhage in trauma protocol be activated? (3)

Answer 1

Systolic BP <90mmHg following initial crystalloid resuscitation (no more than 2 litres)

AND

Suspected active haemorrhage

AND

A consultant with experience in the management of major trauma authorises its use.

Question 2

Steps of resuscitation: arrest bleeding & restore circulating volume?(5)

Answer 2

Insert two wide-bore peripheral cannulae
Give adequate volumes of warmed crystalloids, colloid and red cells
Early invasive monitoring
Use blood warmer: level 1 rapid infuser and warm air blanket
Frequent ABG including haematocrit

Question 3

Which investigations? (4)

Answer 3

FBC and Coagulation Screen (PT, APTT, fibrinogen) 
Group & crossmatch
Thromboelastography (TEG), if available
Biochemistry (U & E’s, LFT’s)
Repeat ABGs to monitor acidosis 

Repeat FBC, PT, APTT, fibrinogen after blood component replacement

Question 4

Transfusion?

Answer 4

Request “massive transfusion pack 1” (8 units RBC to 4 units FFP)
Administer Pack Red Cells
Transfuse FFP as soon as it is available (average adult dose is 4 units) – administer alongside red cells using separate IV access
Allow at least 40 minutes thawing & delivery time

Administer Tranexamic Acid 1g IV if within 3 hours of the injury, followed by another over the next 8 hours

Question 5

If bleeding persists after MTP 1?

Answer 5

Request “massive transfusion pack 2” (8 RBC, 4 FFP, 2 cryoprecipitate & 1 platelets)

Administer Red Cells & FFP as before

Administer Cryoprecipitate

Administer Platelets

Depending on repeat FBC/clotting screen - continue requesting further massive transfusion pack 2 until bleeding stops

Question 6

When bleeding is controlled repeat FBC & clotting administer further components if..?

Answer 6

Platelets < 80 x 10^9/l – administer 1 adult dose platelets

Fibrinogen < 1.0 g/l – administer 2 pooled doses cryoprecipitate

APTT or PT ratio > 1.5 x normal – administer 4 units FFP

Question 7

Blood transfusion complications? (7)

Answer 7

haemolytic: immediate or delayed
febrile reactions
transmission of viruses, bacteria, parasites, vCJD
hyperkalaemia
iron overload
ARDS
clotting abnormalities
urticaria (FPP)

Question 8

What drug can be given between RBC packages?

Answer 8

Furosemide