Tag Archives: Massive transfusion

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How To Remember To Give The TXA!

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The CRASH-2 study did a good job of demonstrating the value of giving tranexamic acid (TXA) in patients with major hemorrhage. The kicker is that the data seemed to show that the effect was best if given early, and might even be detrimental after 3 hours.

The reality is that most patients with major hemorrhage will present as a trauma activation. And if they really are bleeding badly, they will probably trigger your massive transfusion protocol (MTP). But at the same time, they will probably keep you very busy, and it’s easy to forget to order the TXA.

How can you make sure to start the TXA promptly on these patients? Easy! Check out this picture:

Yes, that’s a cheat sign right on top of the first cooler for the MTP! Have the blood bank include this sign in the cooler, so that everyone can see it when you crack the cooler open to give the first units of blood products.

In most hospitals, TXA is a pharmacy item. It should be stocked in the ED, and not in a far away pharmacy satellite. And don’t forget that TXA is given twice, 1 gram given over 10 minutes (or just IV push for speed), followed by another gram infused over 8 hours.

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ABC: A Quick & Dirty Way to Predict Massive Transfusion

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It’s nice to have blood available early when major trauma patients need it. Unfortunately, it’s not very practical to have several units of O neg pulled for every trauma activation, let alone activate a full-blown massive transfusion protocol (MTP). Is there any way to predict which trauma patient might be in need of enough blood to trigger your MTP?

The Mayo Clinic presented a paper at the EAST Annual Meeting a few years ago that looked at several prediction systems and how they fared in predicting the need for massive transfusion. Two of the three systems (TASH – Trauma Associated Severe Hemorrhage, McLaughlin score) are too complicated for practical use. The Assessment of Blood Consumption tool is simple, and it turns out to be quite predictive.

Here’s how it works. Assess 1 point for each of the following:

  • Heart rate > 120
  • Systolic blood pressure < 90
  • FAST positive
  • Penetrating mechanism

A score >=2 is predictive of massive transfusion. In this small series, the sensitivity of ABC was 89% and the specificity was 85%. The overtriage rate was only 13%.

The investigators were satisfied enough with this tool that it is now being used to activate the massive transfusion protocol at the Mayo Clinic. Although the abstract is no longer available online, it appears to be remarkably similar to a paper published in 2009 from Vanderbilt that looks at the exact same scoring systems. Perhaps this is why it never saw print? But the results were the same with a sensitivity of 75% and a specificity of 86%.

Here’s a summary of the number of parameters vs the likelihood the MTP would be activated:

ABC Score         % requiring massive transfusion
0                                1%
1                               10%
2                               41%
3                               48%
4                             100%

Bottom line: ABC is a simple, easy to use and accurate system for activating your massive transfusion protocol, with a low under- and over-triage rate. It doesn’t need any laboratory tests or fancy equations to calculate it. If two or more of the parameters are positive, be prepared to activate your MTP, or at least call for blood!

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References: 

  • Comparison of massive blood transfusion predictive models: ABC, easy as 1,2,3. Presented at the EAST 24th Annual Scientific Assembly, January 26, 2011, Session I Paper 4. (No longer available online)

  • Early prediction of massive transfusion in trauma: simple as ABC (assessment of blood consumption)? J Trauma 66(2):346-52, 2009.

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Is Too Much Crystalloid a Bad Thing?

All trauma centers have massive transfusion protocols, and they typically spell out the approximate ratios of blood to plasma to platelets. But they do not address the use (or overuse) of crystalloid during these large volume resuscitations.

A multicenter, prospective study was carried out looking at the outcomes after resuscitation from hemorrhagic shock using massive transfusion (at least 10u PRBC in 24 hrs). The patients were severely injured (average ISS 34), and overall mortality and incidence of multi-organ failure was 21% and 65%, respectively. The median amount of crystalloid given was 17 liters, and median red cell transfusion was 14 units in 24 hours.

The authors found that if the crystalloid to PRBC ratio exceeded 1.5:1, morbidity increased significantly. The incidence of multiple organ failure doubled, ARDS tripled, and abdominal compartment quintupled! The authors suggested further research, and did not provide specific strategies for decreasing early crystalloid.

Bottom line: As expected, giving so much crystalloid that we turn people into the Sta-Puft Marshmallow Man is not good. While waiting for additional research, it is probably prudent to try to rapidly achieve definitive control of bleeding and apply gentle use of pressors to decrease the total crystalloid given during resuscitation.

Reference: The crystalloid / packed red blood cell ratio following massive transfusion: when less is more. Presented at the 24th Annual Scientific Assembly of the Eastern Association for the Surgery of Trauma, January 2011.

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Using Your ABCs To Predict Massive Transfusion

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It’s nice to have blood available early when major trauma patients need it. Unfortunately, it’s not very practical to have several units of O neg pulled for every trauma activation, let alone activate a full-blown massive transfusion protocol (MTP). Is there any way to predict which trauma patient might be in need of enough blood to trigger your MTP?

The Mayo Clinic presented a paper at the EAST Annual Meeting today that looked at several prediction systems and how they fared in predicting the need for massive transfusion. Two of the three systems (TASH – Trauma Associated Severe Hemorrhage, McLaughlin score) are too complicated for practical use. The Assessment of Blood Consumption tool is simple, and it turns out to be quite predictive. 

Here’s how it works. Assess 1 point for each of the following:

  • Heart rate > 120
  • Systolic blood pressure < 90
  • FAST positive
  • Penetrating mechanism

A score >=2 is predictive of massive transfusion. In this small series, the sensitivity of ABC was 89% and the specificity was 85%. The overtriage rate was only 13%.

The investigators were satisfied enough with this tool that it is now being used to activate the massive transfusion protocol at the Mayo Clinic.

Bottom line: ABC is a simple, easy to use and accurate system for activating your massive transfusion protocol, with a low under- and over-triage rate.

Reference: Comparison of massive blood transfusion predictive models: ABC, easy as 1,2,3. Presented at the EAST 24th Annual Scientific Assembly, January 26, 2011, Session I Paper 4. Click here to view the abstract.

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How to Predict the Need for Massive Transfusion in the ED

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Massive transfusion is needed in about 3-5% of trauma patients. All Level I and II trauma centers are required to have a massive transfusion protocol.However, the protocol must be triggered in a timely manner to best benefit the major trauma patient.

Trauma surgeons at Vanderbilt validated a simple scoring system that allows accurate prediction of the need for massive transfusion in patients as they arrived in the ED. The system was called the ABC score (Assessment of Blood Consumption). It consists of the following 4 yes/no parameters:

  • Penetrating mechanism (0=no, 1=yes)
  • ED SBP <= 90 (0=no, 1=yes)
  • ED heart rate >= 120 (0=no, 1=yes)
  • Positive FAST (0=no, 1=yes)

The results of ABC when applied to trauma patients in the ED was as follows:

ABC Score         % requiring massive transfusion
0                                1%
1                               10%
2                               41%
3                               48%
4                             100%

This scoring system is simple, easy to use and easy to remember. No laboratory tests are needed, and the information needed can be gathered quickly.

Bottom Line: This is a simple and accurate prediction system for determining the need for massive transfusion in trauma patients. Recommended!

Reference: Cotton et al. J Trauma 66(2) 346-352, 2009.