Category Archives: Resuscitation

Crafting And Refining Your Massive Transfusion Protocol – Part 1

August 11, 2023 The Trauma Pro Leave a comment

Every trauma center needs a massive transfusion protocol (MTP). It automates the preparation and delivery of critical blood products in seriously injured patients. Unfortunately, there are many moving parts, so numerous things can go wrong.

This series of posts will break down the entire MTP process, step by step. Although it is designed for centers developing their first MTP, it also provides valuable information for established centers that want to tweak and optimize theirs. I’ll start today with tips on how to build a solid MTP at your center.

Your massive transfusion protocol is a complex set of processes that touch many, many areas within your hospital. There are five basic components (and a few sub-components) to any MTP, so let’s dig into them one by one. They are:

Universality
Activation
Logistics
- Components
- Runners
- Documentation
- Coolers
Deactivation
Analysis

Let’s scrutinize each one, starting with the first two today.

Universality. This means that there should be one, and only one MTP in your hospital. I’ve seen some hospitals that have one MTP for trauma, one for cardiothoracic surgery, one for OB, one for GI, and on and on. Yes, each of those services deals with patients who are suffering from blood loss. But it’s the same blood that your trauma patients lose! There’s no need to create a protocol for each, with different ratios, extra drugs, etc. This can and will create confusion in the blood bank which may lead to serious errors.

Activation. This consists of two parts: how do we decide to activate, and then how does everyone involved find out that the MTP is actually being activated? I’ll discuss activation criteria later in the series. But what about the notification process? Phone call? Order in the electronic medical record (EMR)? Smoke signals?

The most reliable method is a good, old-fashioned phone call. Do not use your EMR except for documentation purposes. Unless there is a very reliable system in the blood bank that translates an EMR order into an annoying alarm or flashing lights, don’t rely on this at all.

Then decide upon the minimum amount of information that the blood bank needs to begin preparing blood products. This usually consists of a name or temporary patient identifier, sex, and location of activation. Ensure that an ID or transfusion band is affixed to the patient so that wrong blood products are not given in multiple patient events.

In my next post, I’ll continue with the logistics of the MTP.

Resuscitation

Jehovah’s Witnesses And Blood Transfusion Demystified

May 2, 2023 The Trauma Pro Leave a comment

Injury can be a bloody business, and trauma professionals take replacement of blood products for granted. Some patients object to this practice on religious grounds, and their health care providers often have a hard time understanding this. So why would someone refuse blood when the trauma team is convinced that it is the only thing that may save their life?

Jehovah’s Witnesses are the most common group encountered in the US that refuse transfusion. There are more than 20 million Witnesses worldwide, with over 7 million actively preaching. It is a Christian denomination that originated in Pennsylvania during the 1870s.

Witnesses believe that the bible prohibits taking any blood products, including red cells, white cells, platelets or plasma. It also includes the use of any dialysis or pump equipment that must be primed with blood. This is based on the belief that life is a gift from God and that it should not be sustained by receiving blood products. The status of certain prepared fractions such as albumin, factor concentrates, blood substitutes derived from hemoglobin, and albumin is not clear, and the majority of Witnesses will accept these products. Cell saver techniques may be acceptable if the shed blood is not stored but is immediately reinfused.

Why are Witnesses so adamant about refusing blood products? If a transfusion is accepted, that person has abandoned the basic doctrines of the religion, and essentially separates themselves from it. They may then be shunned by other believers.

So what can trauma professionals do to provide best care while abiding by our patient’s religious belief? In trauma care it gets tricky, because time is not on our side and non-blood products are not necessarily effective or available. Here are some tips:

Your first duty is to your patient. Provide the best, state of the art care you can until it is absolutely confirmed that they do not wish to receive blood products. In they are comatose, you must use blood if indicated until the patient has been definitively identified by a relative who can confirm their wishes with regard to blood. Mistaken identity does occur on occasion when there are multiple casualties, and withholding blood by mistake is a catastrophe.
Talk with the patient or their family. Find out exactly what they believe and what they will allow. And stick to it.
Aggressively reduce blood loss in the ED. We are not always as fastidious as we should be because of the universal availability of blood products. Use direct pressure or direct suture ligation for external bleeding. Splint to reduce fracture bleeding.
Aggressively use damage control surgery. Don’t go for a definitive laparotomy which may take hours. Pack well, close and re-establish normal physiology before doing all the final repairs.
Always watch the temperature. Pull out all the stops in terms of warming equipment. Keep the OR hot. Cover every bit of the patient possible with warming blankets. All fluids should be hot. Even the ventilator gases can be heated.
Think about inorganic and recombinant products such as Factor VIIa, tranexamic acid and Vitamin K. These are generally acceptable.
Consider angiography if appropriate, and call them early so their are no delays between ED and angio suite or OR and angio suite.

Bottom line: Do what is right for your patient. Once you are aware of their beliefs, avoid the use of any prohibited products. Speak with them and their family to clarify exactly what you can and cannot do. This is essentially an informed consent discussion, so make sure they understand the consequences. Follow their wishes to the letter, and don’t let your own beliefs interfere with what they want.

Resuscitation

What’s The Difference? Liquid Plasma vs FFP

April 18, 2023 The Trauma Pro Leave a comment

Plasma is an important component of any trauma center’s massive transfusion protocol (MTP). Coagulopathy is the enemy of any seriously injured patient, and this product is used to attempt to fix that problem.

And now there are two flavors available: liquid plasma and fresh frozen plasma. But there is often confusion when discussing these products, especially when there are really three flavors! Let’s review what they are exactly, how they are similar, and how they differ.

Fresh frozen plasma (FFP)
This is plasma that is separated from donated whole blood. It is generally frozen within 8 hours, and is called FFP. However, in some cases it may not be frozen for a few more hours (not to exceed 24 hours total) and in that case, is called FP24 or FP. It is functionally identical to FFP. But note that the first “F” is missing. Since it has gone beyond the 8 hour mark, it is no longer considered “fresh.” To be useful in your MTP, it must be thawed, and this takes 20-40 minutes, depending on technique.

Thawed plasma
Take a frozen unit of FFP or FP, thaw, and keep it in the refrigerator. Readily available, right? However, the clock begins ticking until this unit expires after 5 days. Many hospital blood banks keep this product available for the massive transfusion protocol, especially if other hospital services are busy enough to use it if it is getting close to expiration. Waste is bad, and expensive!

Liquid plasma (never frozen)
This is prepared by taking the plasma that was separated from the donated blood and putting it in the refrigerator, not the freezer. It’s shelf life is that of the unit of whole blood it was taken from (21 days), plus another 5, for a total of 26 days. This product used to be a rarity, but is becoming more common because of its longer shelf life compared to thawed plasma.

Finally, a word on plasma compatibility. ABO compatibility is still a concern, but Rh is not. There are no red cells in the plasma to carry any of the antigens. However, plasma is loaded with A and/or B antibodies based on the donor’s blood type. So the compatibility chart is reversed compared to what you are accustomed to when giving red cells.

Remember, you are delivering antibodies with plasma and not antigens. So a Type A donor will have only Type B antibodies floating around in their plasma. This makes it incompatible with people with blood types B or AB.

Type O red cells are the universal donor type because the cells have no antigens on the surface. Since Type AB donors have both antigens on their red cells, they have no antibodies in their plasma. This makes AB plasma is the universal donor type. Weird, huh? Here’s a compatibility chart for plasma.

Next time, I’ll discuss the virtues of the various types of plasma when used for massive transfusion in trauma.

Resuscitation

Emergency Intubation: ED or OR?

March 24, 2023 The Trauma Pro Leave a comment

Decades ago, intubation of trauma patients only took place in the operating room, and only anesthesiologists performed it. As the discipline of Emergency Medicine came into being in the 1980s, emergency physicians became skilled in this procedure. Occasional trauma intubations had to occur in the ED, and typically anesthesia was called for it.

As the emergency physicians became more comfortable and improved their skills, they also started intubating. I distinctly remember a paper from the time (which I unfortunately do not have a reference to) stating that ED and OR intubation were equally safe if the ED intubation field could be made to look like the OR. This thinking has become commonplace, and in most trauma centers, intubation is now provided nearly exclusively by emergency physicians. Anesthesia is called only for extremely difficult cases.

But we have all been involved in cases where the patient is severely injured, usually hypotensive, and crashes and burns during or immediately after the procedure. This is likely due to a combination of loss of sympathetic tone due to the drugs administered, increased vagal tone from instrumenting the airway, and hypovolemia.

Authors from the University of Wisconsin, University of Pennsylvania, and Johns Hopkins hypothesized that ED intubation for patients requiring urgent operation for hemorrhage control was associated with adverse outcomes. They performed a three-year registry study from the National Trauma Program Databank of patients requiring laparotomy for hemorrhage control within 60 minutes of arrival. They excluded the dead and nearly dead (DOA, ED thoracotomy) and patients with immediate indications for intubation (head, neck, or facial trauma). They compared mortality, ED dwell time, blood transfusions, and major complications between patients with ED vs. OR intubation.

Here are the factoids:

Nearly 10,000 patients from 253 Level I or II trauma centers were included in the study
About 20% of patients underwent intubation in the ED, and they were more likely to have blunt trauma mechanism and higher ISS (22 vs. 17)
Initial vital signs were not clinically significant between the ED and OR groups
Mortality in the ED group was significantly higher (17% vs. 7%), the ED dwell time was significantly longer ( 31 vs. 22 minutes), required significantly more blood transfusion (6 vs. 4 units), and had a significantly higher risk of major complications (specifically cardiac arrest, AKI, and ARDS)
There was a wide variation in the rate of ED intubation across all the hospitals. Centers with the highest rate of ED intubations were 5x more likely to intubate than the lowest rate centers. The patient case mix could not explain this difference.
The lower ED intubation rate hospitals tended to be nonprofit Level I university hospitals
Centers with high levels of hemorrhage control surgery were more likely to intubate in the OR

Bottom line: From a purely technical perspective, the old dogma about patient location not making a difference is basically true. The process of getting an airway safely into the patient and secured is equivalent wherever it is done as long as the lighting, equipment, and skill levels are equivalent.

But when one considers the physiologic aftermath of this process, things are obviously more nuanced. Actively bleeding patients are extremely challenged, down to their organ and cellular levels. Disrupting their normal compensatory mechanisms is clearly associated with a significant downside.

We should clearly distinguish the patient who needs an airway for airway’s sake or cerebral protection from one who needs to be in the OR for bleeding control. Other papers have shown that mortality increases as each minute ticks by in the hemorrhaging patient. Trauma programs need to monitor these patients and do a performance improvement deep dive into all trauma patients intubated in the ED to ensure appropriate decision-making.

Reference: Emergency Department Versus Operating Room Intubation of Patients Undergoing Immediate Hemorrhage Control Surgery. Journal of Trauma and Acute Care Surgery, Publish Ahead of Print
DOI: 10.1097/TA.0000000000003907

Abstracts, Resuscitation

Best Of EAST 2023 #6: The Best Place To Intubate Bleeding Patients

January 10, 2023 The Trauma Pro Leave a comment

Forty years ago, the presumption was that the best way to intubate a trauma patient was to take them to a fully equipped operating room and have an anesthesiologist perform it. Then, a few years later, we finally figured out it could be done in the emergency department. The key to doing it safely was that the trauma bay needed to look like an OR, with appropriate airway equipment, lights, and drugs. And you had to ensure that your intubator had sufficient skills.

But we are all too familiar with one subset of trauma patients much more sensitive to the intubation process: those who are bleeding and in shock. They are desperately compensating to attempt to maintain their vital signs as much as they can with their sympathetic tone. Unfortunately, the intubation process and the drugs we use can eliminate this reflex and lead to immediate hemodynamic collapse.

The trauma group at Johns Hopkins postulated that intubation in the ED could lead to worse outcomes in this particular group of patients. They analyzed three years of data from the National Trauma Data Bank dataset, isolating patients at Level I and Level II trauma centers who underwent immediate hemorrhage control surgery after arrival. Patients who were dead on arrival, intubated for airway concerns, or underwent resuscitative thoracotomy were excluded.

The authors used a regression model to determine any association between intubation and mortality. They also analyzed the usual secondary outcomes (complications [cardiac arrest, ARDS, AKI, sepsis], transfusions, and time in the ED).

Here are the factoids:

Nearly ten thousand patients at 253 trauma centers met inclusion criteria
Most patients were men with penetrating injury
One in five underwent intubation in the ED before their hemorrhage control operation and suffered a 17% mortality rate vs. 7% in the OR intubation group, which was a significant difference
Median dwell time in the ED was 31 minutes vs. 22 minutes in the OR group
Transfusion amount was significantly higher in the ED vs. OR group (6 vs. 4 units RBC)
Rates of all complications were significantly higher in the ED vs. OR groups (except sepsis)
Overall, cardiac arrest with CPR occurred in 10% of ED vs. 4% OR intubations
Centers that had low ED intubation rates generally had significantly lower post-intubation cardiac arrest events than those with higher ED intubation rates.

The authors concluded that ED intubation of patients requiring hemorrhage control was associated with multiple adverse events. They recommended that these patients be taken to the OR, where both intubation and rapid bleeding control can be achieved.

Bottom line: This nice, clean abstract addresses a simple question. Although it uses a large database, the authors focused on a limited number of variables, keeping the analysis uncomplicated.

The abstract paints a clear picture that agrees with the subjective observations of many trauma professionals that intubation in these patients can be dangerous. They found significant increases in mortality and complications in patients intubated in the ED.

Does this mean that the procedure is not being done as well there? Absolutely not! I believe the key is in the ED dwell time data, which shows an average of 9 more minutes spent there for intubation. Previous research has shown how even a few minutes count when it comes to hemorrhage control. This abstract provides some hard numbers that show how important it really is to get to the OR.

Here are my questions and comments for the presenter/authors:

First, a minor point: how can the “median” GCS be 15? Fifteen is the highest it can go. The median is the number where half the results are higher and half are lower. So if no results can be higher, none can be lower. Does this mean that every one of your 10K patients was wide awake?
Please explain the figure a little better. Does it just show the mix of low vs. average vs. high ED intubation rates? Or does it go along with the statement that high intubation rate centers have a higher likelihood of cardiac arrest in these patients?

I really enjoyed this abstract and am looking forward to any additional details provided at the presentation.

Reference: EMERGENCY DEPARTMENT VERSUS OPERATING ROOM INTUBATION OF PATIENTS UNDERGOING IMMEDIATE HEMORRHAGE CONTROL SURGERY, EAST 2023 Podium paper #13.

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