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Dr. Ajith Kumar J MD
Dept. of Emergency Medicne
Travancore Medicity, Kollam
India
editor
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.
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Updated on 13/5/13.
Reference
Surgicalcriticalcare.net
Tintinalli
Massive Transfusion Protocol Up's RBCs, Plasma : ACEP 2010
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emmedonline
Dr. Ajith Kumar J MD
Dept. of Emergency Medicne
Travancore Medicity, Kollam
India
editor