Massive Transfusion Protocol

Trauma Rounds (9/23/15)

Article Inspired by: Dr. Paul Mello (EM PGY-4) and Dr. Nikita Shah (Surgery PGY-4)

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THE CASE

10:06am: EMS Notification- 89 y/o M, pedestrian struck, No LOC, alert and oriented, Takes Plavix, Hypotensive on scene = level 1 trauma notification

Initial ER Vitals:

BP: 80/palpable, HR-75, RR-18, Temp-unable to obtain, SpO2-89% (room air)

Primary Survey:

• A: Airway intact, phonating, no trauma noted
• B: B/l breath sounds, Equal chest rise
• C: Hypotensive, Palpable distal pulses, Right 18g antecubital IV noted via EMS, Left 18g antecubital IV placed
• D: Initial GCS 15, PERRL (3mm b/l), Able to move all fingers/toes, Answering questions appropriately
• E: Log rolled; No palpable step-offs, mid thoracic spine tender to palpation; Normal rectal tone, no gross blood; Left lower leg deformity with tibia protruding through midshaft anterior/medial aspect

AMPLE History:

• A: No known medical allergies
• M: Plavix, ASA
• P: DM, CAD (s/p stents), Diverticulitis (s/p operative intervention), Malaria
• L: cannot recall last meal
• E: Reports struck by vehicle while crossing street and denies LOC

Resuscitation:

• FAST negative
• Intubated for airway protection with video laryngoscopy using ketamine and succinylcholine
• R femoral cordis placed and started on MASSIVE TRANSFUSION PROTOCOL– received 4 units PRBCs, 4 units FFP, and 1 unit platelets
• Fractured leg splinted
• Started on Levophed and taken for additional imaging
• CT head: small subarachnoid/sub-pial hemorrhage
• CT chest/abdomen/pelvis: Moderate b/l pleural effusions, L PTX 30-40%, Small area of hemorrhage w/in R pleura, L 2^nd rib displaced/comminuted fractures, Left 3-10 displaced rib fractures, Comminuted fracture of L scapula
• CT cervical/thoracic/lumbar spine: Fracture through superior aspect Fracture through superior aspect of T8 vertebral body with displacement of anterior cortex and hematoma, Minimally displaced fracture of T7 tranverse process, Chronic depression deformity of L1 vertebral body
• Bilateral chest tubes placed with 1200cc of blood noted to drain from R chest tube
• Admitted to Surgical ICU

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THE TALK

MASSIVE TRANSFUSION PROTOCOL

• Used in trauma, major surgeries, GI bleeds, OB hemorrhage, etc and a/w high mortality
• Various definitions
  • Replacing patient’s total blood volume in <24 hours
  • Acute administration of >1/2 patient’s blood volume an hour
• Physiologically, compensatory mechanisms can maintain perfusion to vital organs until ~30% total body volume loss

WHY HAVE A PROTOCOL INSTEAD OF JUST MASSIVE TRANSFUSION?

• To stop the lethal triad of coagulopathy, acidosis, and hypothermia
• Coagulopathy
  • Tissue trauma → activation and consumption of coagulation factors
  • Prolonged shock, Hypoxia, Hypothermia, Failure to clear activation peptides (act as competitive inhibitors) → Reduced activity of coagulation factors
  • Blood replacement → Dilutional effects on coagulation proteins and platelets
• Acidosis (excess protons)
  • Interferes with assembly of coagulation factor complexes involving calcium and negatively-charged phospholipids → delayed production and reduced concentrations of generated thrombin → delayed fibrin production, altered fibrin structure, and increased susceptibility to fibrinolysis
• Hypothermia
  • Reduces the enzymatic activity of plasma coagulation proteins
  • Prevents activation of platelets via traction on the glycoprotein Ib/IX/V complex by von Willebrand factor
    • Seen at core temperatures of 34ºC and below

HOW DO I KNOW WHAT TO REPLACE?

• Crystalloid solutions will replace the deficit in blood volume
• Red cells will improve and maintain tissue oxygenation
• HOWEVER, both of these will result in gradual dilution of plasma clotting proteins
  • Adults: ~10% decrease in concentration of clotting proteins for each 500mL blood loss replaced
  • If coagulation protein levels falls <25% of normal (usually after receiving 8-10units red cells in an adult), additional bleeding can occur
  • Therefore, should monitor PT, aPTT, fibrinogen in massive transfusion protocol
  • If PT, aPTT, fibrinogen > 1.5 times the control, 2-8 units of fresh frozen plasma
    • Each unit of fresh frozen plasma increases clotting protein levels by ~2.5%
    • Cryoprecipitate can be used when fibrinogen levels <100mg/dL
• Both of these will also have similar dilutional effect on platelet concentration
  • Adult: ~10-12 units of transfused RBCs are associated with a 50% fall in platelet count
    • Each unit of platelet should increase platelet count by 5000/microL
• THEREFORE, should measure PT, aPTT, fibrinogen, platelet count after ~5-7 units of red cells

OKAY, BUT WHAT ABOUT WHEN I AM IN THE TRAUMA BAY?

• For trauma, hemodynamic stability is the key indicator for transfusion:
  • Expected/ongoing bleeding
  • Dropping hemoglobin
  • Hemorrhagic shock/low systolic blood pressure/tachycardia
• In trauma, goal is 1:1:1 (units of transfused FFP to units of platelets to units of pRBCs)
  • Blood transfused will have
    • Coagulation factor concentration of 65% of normal
    • Platelet count of 88 x 10⁹/L
    • Hematocrit of 29%
  • BUT taking into account that 30% of platelets and 10% of RBC administered will not circulate, effective concentrations of blood given:
    • Plasma coagulation factor concentration of 65%,
    • Platelet count of 55 x 10⁹/L
    • Hematocrit of 26%

HMM, WHAT CAN GO WRONG?

• Inadequate resuscitation
  • Administering excessive crystalloids (if patient presenting with uncontrollable hemorrhage/shock, typically have lost 30-40% of blood volume)
    • >50% dilution of coagulation factors
    • Diminution of thrombin generation
  • Hypoperfusion
    • Lactic acidosis
    • SIRS
    • Disseminated intravascular coagulation
    • Multiorgan dysfunction
• Over-resuscitation
  • High arterial/venous pressures → can dislodge hemostatic clots
  • Increased hydrostatic pressure → interstitial edema → abdominal compartment syndrome
  • Transfusion associated circulatory overload (usually elderly, small children and patients with compromised left ventricular function)
• Transfusion related issues
  • Metabolic alkalosis
    • pH of unit of blood is 7.10 at 37C due to citric acid
    • pH drops 0.1 pH unit/week due to production of lactic and pyruvic acids by the red cells
    • Metabolism of citrate in each unit of blood → 23 meq of bicarbonate
    • With renal ischemia, excess bicarbonate cannot be excreted in the urine → metabolic alkalosis
  • Hypokalemia
    • Potassium moves into cells in exchange for hydrogen ions that move out of the cells to minimize the degree of extracellular alkalosis
  • Hypocalcemia
    • Each unit of blood anticoagulated with ~3g citrate
    • Healthy adult liver metabolizes 3g citrate every 5 minutes
    • Transfusion at rates higher than 1 unit every 5 minutes or impaired liver function can lead to higher levels of citrate (which binds to ionized calcium)
  • Hypothermia
    • 6 units of RBCs at 4C will reduce body temperature of 70kg adult by 1C
    • Evaporative heat loss from open body cavity (ex: surgery)- decrease by 1C in 40 minutes
  • Hyperkalemia (in infants or patients with renal impairment)
    • Potassium leakage due to prolonged blood storage or irradiation
  • ARDS/TRALI (Transfusion related acute lung injury)

REFERENCES

Melo, P., Shah, N. “Trauma Rounds: Massive Transfusion Protocol” Jacobi Medical Center. Jacobi/Montefiore Emergency Medicine Conference. Bronx. Sep 2015. Lecture

Hess, John R., MD, MPH. “Massive Blood Transfusion.” Massive Blood Transfusion. UpToDate, Feb. 2015. <http://www.uptodate.com/contents/massive-blood-transfusion?source=search_result&search=massive%2Btransfusion%2Bprotocol&selectedTitle=1~150&gt;

“Transfusion for Massive Blood Loss.” Transfusion for Massive Blood Loss. Trauma.org. <http://www.trauma.org/archive/resus/massive.html&gt;.

Patil, Vijaya, and Madhavi Shetmahajan. “Massive Transfusion and Massive Transfusion Protocol.” Indian Journal of Anaesthesia. Medknow Publications & Media Pvt Ltd, Sept-Oct. 2014. <http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4260305/&gt;.

Thoracotomy

‘Make your intentions honorable.’ -John Hinds

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The case below was presented in Trauma rounds, July 22nd, 2015, by Dr. Benjamin Chan (EM-4).

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CRACKING THE CHEST: Where’s the Foley?

It could have potentially been a quiet night — a Tuesday, or maybe it was a Sunday overnight. My second Bronx summer as an emergency medicine resident had just started, and ‘graduated responsibility’ was on my mind. The 4^th of July and its penchant for crazy firework trauma had come and gone relatively peacefully. The EMS notification phone, however, has a distinct ring-tone with the uncanny ability to pierce the quiet, penetrating the furthest reaches of the Jacobi ED. I was in one of those reaches, in the yellow zone, ultrasound probe in hand about to scan the gallbladder of a middle-aged woman with abdominal pain. I quickly apologized and stepped out.

As a first year, when the EMS notification phone rang, I heard it, but would invariably keep doing what I was doing until the call was made overhead for us to gather in the acute resuscitation bays. Sometimes the calls are for the team on the opposite side of the ED, in which case I could disregard and keep working. This year, however, I’ve started to migrate towards the trauma bays, peering over the shoulder of the nurse taking report from EMS. If the call is for the other team I can go back to Yellow and my search for gallstones. This year, as second years, our senior residents are assigning us the sickest trauma patients. I’ve stopped waiting for the overhead call. It was my turn, and I’ll take the extra time for preparation if I can get it.

“Young adult male — stab wound to the left chest.” The nurse states in a monotone voice while jotting details on a notepad, phone nestled in the shrug of her right shoulder. “Intubated in the field.” Next line. “Heart Rate 130s, blood pressure 70/palp.” The acute resuscitation bays sit a stone’s throw from the clerks’ desk, and I hustle over as the nurse who took the call hangs up and makes the announcement overhead. I grab a mask and secure it behind my ears, feeling my own heart rate thump in my chest. I take a few deep breaths, but my sympathetic nervous system has shifted into overdrive. Gown and gloves on. My senior resident and I are on the same page; I place a scalpel, bottle of betadine, 36 french chest tube, and the chest tube pack onto the tray situated on what will be the patients left side. I grab a #ten- and #eleven- blade scalpel. For a split second it registers that the two blades are very different. I’d never been told, nor thought to ask which is preferred for a chest tube. I’m sure, though, that both work, and this really isn’t the time. The previous year my attending had good-naturedly prodded me to try “not to look like a chump in front of the trauma surgeons,” so I’d been practicing my hand-ties at home. Pretending that a giant salad spoon was the chest tube, I’d been revisiting knots I hadn’t done since my surgical rotation in medical school. My chest wall still thumping away, I think I’m ready in the eventuality that this young man, still en route via ambulance, would need a chest tube. Lungs, heart, great vessels, and injury to any and all of them were the thoughts running through my head. I kept trying to take deep breaths.

A Level 1 trauma notification is called — there are different categories of trauma, 1 being the most acute and means a trauma attending and chief would be arriving to the bay soon — and an EM senior resident, who generally covers the airway on trauma cases, is assigning roles. We have a nurse, an EM attending, another 2^nd year on vascular access, and myself, whose job, at least initially, will be to perform the primary survey. Looking out the trauma bay, we’re all gowned-up; EMS will be arriving from the right.

All of a sudden there’s a slight increase, audible, but not yet visible from our vantage point, in the level of commotion at the ambulance bay. Moments later I see a young man, on his back on the gurney, he looks sweaty. My eyes track to the EMS monitor, he’s got a pulse, and he’s moving (signs of life (Hunt, 2006)). There’s blood on his left chest. EMS is bagging him via their endotracheal tube placed in the field as he’s rolled into resuscitation bay 1. EMS reports that not much is known; “he was found down, penetrating trauma to left anterior chest, large-bore intravenous access obtained, intubated on the scene.”

I thrust my stethoscope onto the left chest; I think it sounds decreased. I move to the right chest for comparison, better. I go for the axilla, still trying to somehow ignore the ambient noise of the trauma bay — still decreased on the left. “Decreased breath sounds on the left!” I try not to yell.

EM and trauma attending, in unison command, “Chest tube on the left, now.” Betadine goes on first, sterile gown and gloves in quick succession. I choose the #ten blade scalpel and am just barely piercing the skin at the superior border of the rib sitting in the anterior axillary space just superior to the nipple line. “We lost pulses,” says a voice to my left with his hand on the femoral artery. “No pulse.” Without hesitation, the decision is made to scratch the chest tube and move to thoracotomy.

The decisiveness made an impression. There was no debate, we hadn’t yet checked a subxiphoid ultrasound image that might hint at reasons for cracking the chest (Inaba, 2015). Both our EM and Trauma attending knew the indications, literature, process, complications of the thoracotomy so well, that the decision to proceed was almost matter-of-fact. The procedure seemingly takes no time (initiated by the trauma chief resident, and completed by the trauma attending) as the incision for a left anterolateral thoracotomy (Flaris, 2015) is competed and the steel rib-spreaders open up the 5^th intercostal space large enough to fit your head through; there sits a very large heart, no obvious bleeding.

I’m holding the patient’s left arm above his head, out of the way. Everyone has a role; I’ve become part of the thoracotomy team. The heart is fibrillating on the monitor, the heart is visibly fibrillating in his open chest. Tamponade physiology recognized, and the right hand of the trauma attending leans in, makes an incision in the pericardium and a torrent of blood shoots out. I put my right hand out and try to the block the arterial spray. It’s hot, and it’s all over our gowns. The trauma attending sees where the blood is coming from and asks for a Foley catheter, which our EM attending has, shockingly to me, in his hand, and smoothly passes it from his position at the foot of the bed over to the left side of the stretcher as soon as it’s requested. The Foley is placed into the cardiac wound and balloon inflated to stop the bleeding. The scariest moment for me, is when the trauma attending shouts for a stapler, which thankfully was in the second drawer that I frantically throw open. Cardiac message (using two-handed, hinged clapping motion) is initiated and the patient is shocked twice using the long black internal paddles, one placed on each side of the heart. Epinephrine is drawn up in a syringe and delivered directly to the heart. I’m trying to maneuver the overhead lights, but can’t swing it low enough to get the beam into the thorax. I break out my Maglite-style penlight and shine it into the open cavity, doubtful, but hopeful that it’s helping the trauma chief and attending see what they’re looking at. Foley inserted, incision stapled, normal sinus rhythm on the monitor, we move out of the ED, into an elevator being held open by a medical student, to the third floor, around the corner and into the operating room. Once in the OR, the patient is fully in the hands of the surgical team. I grab the portable monitor to scurry back down to the ED, “let me know how it goes.” I say as I back out of the OR. On the way downstairs I pass a surgical resident who asks, dubiously, how our patient is doing, probably knowing only that this patient had just had his chest opened in the ED. “Should I continue to try to clear an intensive care unit bed?” I think so.

Forty-five minutes later, a second level 1 trauma is called. Chest thumping, I’m trying to get those deep breaths going. Standing in the trauma bay, my senior resident is again assigning roles. I overhear the trauma attending on the phone with his chief resident who is still in the OR closing up the ED thoracotomy patient. “Please close faster,” he calmly requests. Six days later, the young man walked out of the hospital.

The foresight my attending had to have a Foley catheter in his hand and anticipate it’s utility in the event of a cardiac stab wound has left a huge impression. He was overseeing the most critical of resuscitations but at some point had looked 10 steps ahead and was prepared. In contrast, I became frantic, searching for a stapler. Terms like graduated responsibility, competency, and milestones are tossed around often in residency training circles. My definition of success in residency is when you learn to anticipate and act, rather than react and flounder.

Practically, it means proper preparation as a routine. It doesn’t always work out, but I try to show up to my shifts a little early. I use this time to swing by the resuscitation bays and ensure they’re stocked with the things we might need in a pinch. Sometimes, loading my pockets with saline flushes, IVs, a bottle of betadine and a scalpel. EMS pre-notification the prep work includes making sure the ultrasound machine is on and both the phased array and linear probes are attached and working prior to patient arrival. Setting up a chest tube tray even if there’s only a slight chance it will be needed. Trying to be like my attending that night and know what’s going to happen ahead of time.

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THE PROCEDURE:

Who gets one? The Eastern Association for the Surgery of Trauma (EAST) provides 6 scenarios based on 72, largely retrospective, studies of over 10,000 patients who underwent ED thoracotomy (Seamon, 2015). The 6 scenarios are based on 6 distinct populations depending on presence or absence of signs of life, and whether the injury was penetrating (thoracic or extra-thoracic) or blunt.

• Strongly recommended: Pulseless with ‘signs of life’ (defined as; pupillary response, spontaneous ventilation, carotid pulse, measurable or palpable blood pressure, extremity movement, or cardiac electrical activity) after penetrating thoracic injury.
• Strongly favored: Pulseless without signs of life after penetrating thoracic injury.
• Conditionally recommended: Pulseless with signs of life after penetrating extra-thoracic injury.
• Conditionally recommended: Pulseless without signs of life after penetrating extra-thoracic injury.
• Conditionally recommended: Pulseless with signs of life after blunt injury.
• Conditionally not recommended: Pulseless without signs of life after blunt injury.

Keep in Mind:

• Decide quickly, ACLS doesn’t work for traumatic arrest, don’t do 6 minutes of CPR then decide to crack chest. Open or call it.
• Cut, following the curve of the rib (beneath nipple in male or along inframammary fold in female), so that it opens wide enough without revision.
• Spread the intercostal space with rib spreaders.
• Second team continuing the resuscitation. Obtain venous access. Right subclavian central line, intubation, calling for blood, transfusing. Consider chest tube for right chest.

Now what? Relief of Tamponade (Bokhari, 2004 & Bartlett, 1998):

• If endotracheal tube wasn’t mainstemmed, left lung will be popping out at you. Push lung into chest, superiorly and laterally to expose the pericardial sac. Grab the heart and lift.
• Pick up the pericardium. Make an incision, avoiding the phrenic nerve, which appears as a white or yellow strand. It sits laterally, so aim for most anterior aspect of heart (the apex, closest to ceiling). You’ll know that you are through pericardium when you can see heart, or blood starts spurting out. Pericardial fluid should normally be straw-colored, without any hint of red. If nothing comes out, there was no pericardial tamponade, and the patients chance of survival markedly declines (Cipolle, 2012).
• If blood, extend the nick you’ve made in the pericardium, from the top to the bottom parallel to phrenic nerve (from the apex of the heart to the aorta).
• Fully expose heart. Deliver the heart from the pericardium and inspect it for any injury. Inspect anteriorly and laterally, if you still can’t find where the blood is coming from gently lift up the heart and see if there’s anything posterior.
• If you find a wound anteriorly, still check posterior; there could be a through-and-through injury. Don’t try and stitch the heart. Put your finger on the hole; digital occlusion of small cardiac wounds can provide excellent hemostasis. Don’t place your finger in the hole as this could increase the size of the wound. Another method of temporary hemostasis is to place a 14 or 16 foley in the hole, fill with saline until just bigger than hole.

Control Hemorrhage:

• Cross clamp pulmonary hilum in cases of pulmonary hemorrhage. Alternatively, push lung down until you see heart. Find inferior pulmonary ligament and cut it. Take entire lung and twist it 180 degrees for vascular control.
• Intercostal bleeds are a very survivable injury, bleeding will be coming from behind lung. Hold pressure.
• Injuries to thoracic great vessels (pulmonary artery and vein, vena cava, aorta, innominate artery, subclavian artery and vein) are a cause of significant morbididy and mortality. Cross clamp to control hemorrhage.

The young man walked out of the hospital 6 days after arriving; back out into the Bronx summer. I wonder what he thinks, or knows, about all that has occurred. He’s taught me quite a bit.

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References:

Bartlett, R. (1998). Resuscitative Thoracotomy. In J. Roberts & J. Hedges (Eds.) Clinical Procedures In Emergency Medicine (pp. 264-279), Philadelphia, PA: W.B. Saunders Company.

Bokhari, F. (2004). Emergency Department Thoracotomy. In E. Reichman & R. Simon (Eds.), Emergency Department Procedures (pp. 256-261). New York, NY: McGraw-Hill.

Cipolle M et al. Deadly dozen: dealing with the 12 types of thoracic injuries. JEMS. 2012 Sep. 37 (9):60-5.

Flaris, A et al. Clamshell Incision Versus Left Anterolateral Thoracotomy. Which is Faster When Performing a Resuscitative Thoracotomy? The Tortoise and the Hare Revisited. World Journal of Surgery. 2015 May; 39(5): 1306-1311.

Hunt PA, Greaves I, Owens WA. Emergency thoracotomy in thoracic trauma — a review. Injury. 2006 Jan;37(1):1-19. Epub 2005 Apr 20.

Inaba, K. et al. FAST Ultrasound Examination as a Predictor of Outcomes After Resuscitative Thoracotomy: A Prospective Evaluation. Ann Surg. 2015 Sept; 262(3): 512-18.

Seamon MJ et al. J Trauma Acute Care Surg. July 2015; 79: 159-173