EMmedonline

• Massive transfusion is universally accepted as the replacement of patients blood volume or transfusion of >10 units of PRBC over a period of 24hrs.

• Massive transfusion is considered in the presence of

  • SBP <90mmHg

  • HR >120 beats per minute

  • Positive focused sonography for trauma (FAST)

  • pH<7.2

Pathophysiology

• Acidosis, hypothermia, coagulopathy forms the lethal triad in trauma.

Dilutional Coagulopathy

• In patients requiring massive transfusion of blood products, minimize crystalloid resuscitation to prevent dilutional coagulopathy.

Consumption Coagulopathy

• Exposure of TF at the site of injury, leading to activation of the coagulation cascade at this site. Massive injury may cause extensive consumption with depletion of platelets and coagulation factors.

Hypothermia

• Body temp <33 C produces a coagulopathy that is functionally equivalent to factor deficiency states when coagulation factor concentarion is less than 50%.

• Hence moderate or severe hypothermia should be corrected.

• PT & aPTT values from the lab underestimates the magnitude of coagulopathy.

• Place convective-air or aluminium space blanket over the patient.

• Use humidified mechanical ventilator circuits warmed to 41C.

• Use fluid warmers for the infusion of fluid at 42C.

• For refractory hypothermia consider pleural/peritoneal lavage or arteriovenous warming.

Acidosis

• Acidosis directly reduces the activity of the extrinsic and intrinsic coagulation pathway as measured by PT & PTT, and also dimishes platelet function.

• Metabolic acidosis is corrected by correcting hypoperfusion.

• Bicarbonate administration is considered when pH<7.2 despite optimal fluid and inotropic support.

Thus acidosis, hypothermia and coagulaopathy makes a lethal triad in trauma patient.

Management

Blood Products

• Current recommendation is to transfuse PRBC, FFP & Platelete in 1:1:1 ratio. It is based on various military and civilian studies of massive transfusion.

Tranexemic acid

• Early administration within first 3hrs of trauma can be effective as shown in CRASH 2 trial.

• 1gm of tranexamic acid is given over 10min followed by infusion of 1gm over 8hrs.

Prevent hypothermia by covering with blankets, warm fluids etc.

Role of Factor VIIa

Updated on 13/5/13.

Reference

• Surgicalcriticalcare.net

• Tintinalli

• Massive Transfusion Protocol Up's RBCs, Plasma : ACEP 2010