an acute transfusion protocol for severe blunt trauma, and ... · ‘’an acute transfusion...
TRANSCRIPT
‘’An acute transfusion protocol for severe blunt trauma, and what we might do when
FFP is not immediately available’’
Kotaro Sorimachi
Fukushima Medical University
Emergency and Critical Care Medicine
Introduction
• It’s important for patients with massive bleeding due to severe blunt trauma to transfuse early, especially to maintain or restore hemostasis.
•Protocol for massive transfusion is useful for fast response in emergencies.
Clinical Question
Is our protocol effective for hemostasis and survival?
Our hospital’s protocol
• Severe blunt trauma• Unstable pelvic fracture is suspected• FAST (Focused assessment with sonography for trauma) (+)
Shock vitals+
6 units* of type O Red Cell Concentrates (RCC)
4 units* of type AB Fresh Frozen Plasma (FFP)
First information
Order before arrival
*A “unit” in Japan is based historically on a 200 mL whole blood donation.
Period : 1 year (Jan – Dec 2016)
Number : 15 (Male : 10)
★Average utilization★
RCC 3.5 units/patient
FFP 0.2 units/patient
How often did we use this protocol ?
Why the low utilization of FFP?
• Thawing time : about 20 min
• Fibrinogen concentration : 0.16-0.2 g/dl
Massive transfusion of FFP = Dilutional coagulopathy ??= acquired hypofibrinogenemia
New protocol
• Prepare: MAP + FFP + Fibrinogen 3-6g
• Measure fibrinogen level with ROTEMalong with other lab tests.
(decide the amount of fibrinogen depending on the level)
https://www.rotem.de/en/products/rotem-sigma/
Case using new protocol
30-year-old male
• Traffic accident (car vs car) due to drowsy driving• Head-on collision at 60 km/h
• “Unconscious, in shock” - Ambos→put “Massive Transfusion Protocol”
into action
Vital signs• SpO2 96% (O2 10L), RR 14/min
• BP unmeasurable, HR 114/min, FAST(-)
• GCS E1V1M1, pupils 5mm(-)/5mm(-)
Hemorrhagic shock due to multiple traumatic injuries
traumatic SAHpelvic fracturefemoral shaft fracture
intraperitoneal bleeding
elbow open fracture radial fracture
• ISS(Injury Severity Score)
• RTS(Revised Trauma Score)
• Ps (Probability of survival)
272.33
0.307
First results of ROTEM
MCF : maximum clot firmness
MCF<10mm→hypofibrinogenemia
FIBTEM→for evaluation
・fibrinogen concentration・fibrinogen polymerization reaction
Passage of time
0 15 33time (minutes)
arrivalFibrinogen 6g started
21 30
Fibrinogen 6g started
first ROTEM exam hypofibrinogenemia
RCC transfusion started
Blood test
SpO2 96% (O2 10L), RR 14/minBP unmeasurable, HR 114/min, GCS E1V1M1, pupil 5mm(-)/5mm(-)FAST(-)
Fibrinogen concentration
Before After
fibrinogen : 6g
After recovery of his coagulation system: Hemostasis
IABO inflation
External fixation : pelvis
Laparotomy hemostasis
After initial damage control surgery and subsequent operations, he was transferred to
another hospital for rehabilitation.
DiscussionIs fibrinogen really effective?
• Fibrinogen from thrombin cascade:1 thrombin molecule converts ~1,700 fibrinogen molecules
• When bleeding persists, fibrinogen levels are inadequate to maintain hemostasis.
(Seppo T at el, Hemostatic Factors and Replacement of Major Blood Loss with Plasma-Poor Red Cell Concentrates, Anesth Analg 1995;81:360-5)
For hemostasis…Consider “Concentrated fibrinogen factor” in early term.
Issues
• Fibrinogen infusion isn’t approved for acquiredhypofibrinogenemia.
• 1g fibrinogen needs about 12 persons’ blood donation→expensive (~US$286.50)→theoretical infection risk
• Infusing fibrinogen might improve survival in massive bleeding due to severe blunt trauma.
• Rapid testing and infusion can be incorporated into a massive transfusion protocol.
• Royal Big Smoke? Outback Base? Your thoughts…
Take home message
N(not to scale)
Fukushima Australia