Trauma Massive Transfusion Protocol (MTP)
VBMC TRAUMA CARE SERVICES GUIDELINE
TITLE: Trauma Massive Transfusion Protocol (MTP)
PURPOSE: Coordinate resuscitation for patients suffering massive
hemorrhage, requiring rapid transfusion of massive amounts of multiple types of
blood products.
GUIDELINE:
Hemorrhage is the leading cause of
death in the first hour after arrival at a trauma center, causes 80% of OR
deaths and 50% of deaths in the first 24 hours
(1). A significant number of patients
arrive coagulopathic and mortality is nearly 50% in those patients (versus 10%
of those with normal coagulation on admission)
(2). Massive transfusion protocols
(predefined fixed ration resuscitation) significantly decreases mortality AND
blood product use (ie, ‘go big early’)
(3). MTP’s also reduce
organ failure, sepsis, pneumonia, open abdomens and compartment syndrome
(apparently due to less blood product exposure)
(4). Plasma:platelet:RBC ratios of
1:1:1 reduces exsanguination compared to 1:1:2.
(5). Reaching these targets within 6
hours reduces mortality compared to reaching the targets after 6 hours
(6). Every minute of delay in
receiving the MTP cooler increases mortality
(7). Early plasma, given in the field,
reduces mortality
(8). PCC are associated with improved
outcome in trauma hemorrhage
(9). Whole blood resuscitation is
advocated by the U.S military, has gained significant interest in civilian
trauma centers and is undergoing further evaluation
This guideline is designed to ensure availability of blood
products during massive traumatic resuscitation utilizing early component
therapy for aggressive resuscitation. Its activation is limited to the trauma
chief resident/trauma attending and shall be communicated to transfusion
services upon activation.
The responsibility for notifying transfusion services when
to stop the automatic delivery of blood products is also their responsibility
unless the direct care of the patient has been transferred to another attending
physician who understands they are now responsible for this notification of the
transfusion service if stopped prior to the patient leaving the operating
suite.
Likewise at any time during the MTP should 2 pre-designated
resuscitation “packages” be prepared and not picked up for transfusion,
transfusion services shall contact the circulating nurse in the operating suite
or intensive care unit to have him/her ask the surgeon whether the MTP should
be discontinued before any more blood products are prepared and potentially
wasted.
The MTP should be considered in any trauma patient with
massive hemorrhage and ongoing bleeding, after transfusion of > 8 units of
leuko-reduced red blood cells in a 4 hour period.
The MTP should not be activated in an effort to expedite the
availability of routine quantities of blood products.
Once the protocol is activated by the head or associate of
trauma services, transfusion services shall be notified and respond by placing 4
units of O Negative or type specific (if known) leuko-reduced RBCs and 4 type
AB liquid plasma units in a cooler as the “initial” resuscitation package.
Transfusion Services then continues to prepare
pre-designated resuscitation “packages” of components as indicated by the chart
below. These packages are to be picked up from transfusion services every 30
minutes by the designated courier from the patient care area. (See table 1.)
In addition to hemorrhage control, the attending physician
is responsible for the decision to stop the protocol as well as the decision to
use rFVIIa.
|
Time
|
Package
|
RBC |
FFP |
Platelets
|
Cryoprecipitate
|
Notes
|
|
0 min |
Initial
|
4 |
4 |
0 |
0 |
TEG |
|
30 min |
2 |
4 |
4 |
1 SDP |
0 |
----- |
|
1 hour |
3 |
4 |
4 |
0 |
(4) 5
packs |
Check
ABG, TEG |
|
1.5
hour |
4 |
4 |
4 |
1 SDP |
0 |
Consider
rFVIIa |
|
2 hour |
5 |
4 |
4 |
0 |
(4) 5
packs |
Check
ABG, TEG |
|
2.5
hour |
6 |
4 |
4 |
1 SDP |
0 |
Consider
2nd dose rFVIIa |
|
3 hour |
7 |
4 |
4 |
0 |
(4) 5
packs |
Check
ABG, TEG |
(for continued resuscitation alternate packages 6 and 7)
Note: Once registration changes the patient from the
“trauma” name to an “actual” patient name, this information needs to be
communicated to transfusion services.
The blood bank medical director and trauma medical director
will review each MTP activation for quality assurance using the following
indicators:
▪ Time from initiation to first product availability
▪ Availability of resuscitation packages within 30-minute time frame
▪ Timely delivery of packages to patient care area
▪ Usable (Returnable), Unused, delivered product
▪ Unusable (wasted) Unused, delivered product
▪ Failure to stop MTP in a timely fashion resulting in unused package delivery
RESOURCE/REFERENCES:
Improvements in Early Mortality and Coagulopathy are Sustained Better in Patients With Blunt Trauma After Institution of a Massive Transfusion Protocol in a Civilian Level I Trauma Center. CJ Dente et al. June 2009, Journal of Trauma.
Thromboelastography (TEG)
TEG
Purpose: There are two systems in the blood which interact to allow the
blood to coagulate and maintain hemostasis: the enzymatic proteins (clotting
factors) and platelets (non nucleated cells). PT and aPTT measure
the time it takes to form fibrin clot via the extrinsic and intrinsic pathways
while the platelet count indicates platelet mass (though says nothing about how
well platelets function) (1). When patients experience traumatic injury,
infection, or inflammation these systems are activated, affecting hemostasis
(1).
In trauma, coagulation disturbance
is caused by consumption of clotting factors and dilution from the massive
infusion of crystalloids and RBCs (2). But even before substantial
amounts of fluid resuscitation and RBC transfusion, one-quarter of trauma
patients already have abnormal coagulation parameters, highlighting the
importance of inflammation and fibrinolysis in the coagulopathy of
trauma (3) (1).
To treat the coagulation disturbances
appropriately, an expanded view of coagulation is needed, measuring both
clotting factors and platelet aggregation together. Thromboelastography (TEG)
provides this expanded view of coagulation, measuring clot
formation via the tensile strength of the fibrin-polymer-platelet complex. (1)
In severely injured trauma
patients, Thromboelastography (TEG) will be drawn to guide the
administration of blood products with the goal of improving patient mortality,
reducing the amount of blood required for transfusion, and preventing
unnecessary transfusions (1).
Indications:
1. Level
1 trauma activation
2. MTP
References:
1.Kroll, M, MD Clinical Laboratory
News: Thromboelastography: Theory and Practice of Measuring
Hemostatis , AACC.Org 2012 Dec 32(12)
2.Jeannie L. Callum1,2 and Sandro Rizoli, Assessment and management of
massive bleeding: coagulation assessment, pharmacologic strategies, and
transfusion management, American Society of Hematology , 2012 pp 522-528
3.Victor Jeger, Heinz Zimmermann, and
Aristomenis K. Exadaktylos , The Role of Thrombelastography
inMultiple Trauma doi: Hindawi Publishing Corporation
Emergency Medicine International
Volume 2011, Article ID 895674, 4 pages
4.Cushing,
M;Shaz,B/.H. Blood Transfusions in trauma patients: unresolved
questions. Mineva Anestesiologica, March 77(3): 349-359
5. Holcomb, John B.;
Minei, Kristin M.: et al; Admission rapid thrombelastography can
replace conventional coagulation test in the emergency room department:
Experience with 1974 consecutive trauma patients .Annals of Surgery,
September 256(3): 256(3):476-486