2 Liters. Goal: Basic Algorithm Volume Resuscitation in Trauma. Initial Fluids. Blood. Where do Blood Products Come From?

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1 Goal: Basic Algorithm Volume Resuscitation in Trauma Sanjay Arora MD Associate Professor of Emergency Medicine Keck School of Medicine at USC Los Angeles County + USC Medical Center May 23, 2012 Initial Fluids Blood I use LR Whole blood till 1980s Infection I use NS Storage Waste 2 Liters Where do Blood Products Come From? 500cc 250cc 250cc Component therapy Why Are Platelets So Special? Liquid Gold

2 Transfusion Basics Type and Screen Type and Cross Which one do we do in trauma? O negative O positive Massive Transfusion 10 Units of blood in 12-24/hrs AKA total blood volume 5 Units of blood in 3-6 hours AKA 1/2 total blood volume Reactive Reactive Check labs frequently POC when available Treat coagulopathies when found ATLS reccs FFP:RBC 1:4 Trauma Associated Coagulopathy Why? - Old Thinking Seen in 25-50% of trauma patients Associated with increased mortality Blood loss Dilution during resuscitation

3 Why? - New Thinking Why? - Fancy Math Blood loss Hypothermia Acidosis Consumption Fibrinolysis Dilution during resuscitation Why? - Fancy Math Reactive Assuming 30-40% blood loss, IVFs, 2U PRBC clotting factors already 50% 1:4 or 1:6 you can never catch up Proactive FFP:PLT:RBC 1:1:1

4 Evidence Based Double-blinded Placebo-controlled Randomized Prospective N=246 FFP:PRBC Mortality 1:8 65% 1:2.5 34% 1:1.4 19% Oct 2007 MT Group N = 2746 Aug 2008 N = % received FFP FFP:RBC Mortality 23% 5% No tx <10U PRBC >10U PRBC 23% 5% 1:4 87.5% 1:1 26% 72% 72% <10 U PRBC N = % received FFP FFP:RBC Mortality 23% 5% 72% 1:4 21.2% 1:1 11.8% Retrospective review USC Trauma registry 675 pts MT 5,172 transfusions/32,289 pts 12 and 24 hour mortality Sept 2010

5 Platelet Ratios Group aplt:prbc n Low <1: Medium 1:18, <1:12 77 High 1:12, <1:6 249 Highest 1:6 160 Science Is Not Perfect Combat zones Retrospective Association does not equal causation No way to know why patients with better ratios got more blood products Maybe sickest died before we could act If we adopt fixed ratio transfusions, will we waste blood products? July 2008 Initiated MT protocol at UT Southwestern 132 Patients post and 46 pre No mortality difference Decreased blood product use! Post Pre PRBC 11.8 U 15.5 U FFP 5.7 U 8.7 U PLT 1.1 U 3.8 U What about synthetic blood products? PolyHeme

6 Synthetic RBCs Development began in Vietnam War era Made from human hemoglobin Extracted and purified from expired RBCs Carry oxygen Multistep polymerization process Pitfalls Vasoconstriction Renal failure (free globulin) Interfere with lab tests Spectrophotometrically Myocardial infarction Short intravascular dwell time Desired Characteristics Non-antigenic Normal O2 and CO2 carrying No methemoglobin Store at room temperature No MI/ renal failure Cheap 29 centers, n = 714 Inclusion criteria Age >18 Acute blood loss SBP 90mmHg J Am Coll Surg Vol The Plan PolyHeme versus crystalloid Treatment initiated in field No control over PRBCs Conclusions Patients resuscitated with PolyHeme had outcomes comparable with those for the standard of care Although there were more adverse events in the PolyHeme group, the benefit-to-risk ration of PolyHeme is favorable when blood is needed but not available

7 30 Day Mortality Adverse Events Conclusions Patients resuscitated with PolyHeme had outcomes comparable with those for the standard of care Although there were more adverse events in the PolyHeme group, the benefit-to-risk ration of PolyHeme is favorable when blood is needed but not available What about medications? Tranexamic Acid in Trauma Lancet Mar 2011 C R A S H CRASH-2 Clinical Randomization of an Antifibrinolytic in Significant Hemorrhage

8 Anti-fibrinolytics Mechanism of Action ε amino-caproic acid (Amicar) 5gm IV over 1 hour then 1gm/hr gtt Tranexamic acid 10mg/kg IV q 6-8 hrs Synthetic derivative of amino acid lysine Inhibits fibrinolysis Common uses Treatment of coagulopathies Minimize blood loss in elective surgeries ε amino-caproic(amicar) &Tranexamic acid Plasminogen The Lancet Vol 376 July 3, 2010 tpa Plasmin Fibrin Fibrin Degradation Products (inc D-Dimer) RCT, n = 20, countries/ 274 hospitals Tranexamic acid 1gm IV over 10 minutes then 1 gm IV gtt over 8 hours Outcomes Death at 4 Weeks Primary Death at 4 weeks Secondary Vascular occlusive events Surgical interventions Need for blood transfusion Amount of blood transfused

9 Secondary Outcomes Lancet Mar 2011 How did it work? No difference in PRBC transfusion? Reduction of pro-inflammatory effects of plasmin This occurs early Time Till Treatment Results Risk of Death Tranexamic acid Risk of Death Placebo Relative Risk < 1 hour 5.3% 7.7% hours 4.8% 6.1% 0.79 > 3 hours 4.4% 3.1% 1.44 Take Home Points >2L of fluid, time for blood Be proactive 1:1:1? Warm blood and auto transfuse Trauma associated coagulopathy is real PolyHeme: concept good, product not good CRASH is a high impact trial Tranexamic acid late may cause harm