Creation, implementation, and maturation of a massive transfusion protocol for the exsanguinating trauma patient.

Department of Surgery, Brooke Army Medical Center, Fort Sam Houston, Texas, USA.
The Journal of trauma (Impact Factor: 2.35). 06/2010; 68(6):1498-505. DOI: 10.1097/TA.0b013e3181d3cc25
Source: PubMed

ABSTRACT The majority of trauma patients (>90%) do not require any blood product transfusion and their mortality is <1%. However, 3% to 5% of civilian trauma patients will receive a massive transfusion (MT), defined as >10 units of packed red blood cells (PRBC) in 24 hours. In addition, more than 25% of these patients will arrive to emergency departments with evidence of trauma-associated coagulopathy. With this combination of massive blood loss and coagulopathy, it has become increasingly more common to transfuse early the trauma patients and with a combination of PRBC, plasma, and platelets. Given the inherent uncertainties common early in the care of patients with severe injuries, the efficient administration of massive amounts of PRBC and clotting factors tends to work best in a predefined, protocol driven system. Our purpose here is to (1) define the problem of massive hemorrhage and coagulopathy in the trauma patient, (2) identify which group of patients this type of protocol should be applied, (3) describe the extensive coordination required to implement this multispecialty MT protocol, (4) explain in detail how the MT was developed and implemented, and (5) emphasize the need for a robust performance improvement or quality improvement process to monitor the implementation of such a protocol and to help identify problems and deliver feedback in a "real-time" fashion. The successful implementation of such a complex process can only be accomplished in a multispecialty setting. Input and representation from departments of Trauma, Critical Care, Anesthesiology, Transfusion Medicine, and Emergency Medicine are necessary to successfully formulate (and implement) such a protocol. Once a protocol has been agreed upon, education of the entire nursing and physician staff is equally essential to the success of this effort. Once implemented, this process may lead to improved clinical outcomes and decreased overall blood utilization with extremely small wastage of vital blood products.

  • Simulation in healthcare: journal of the Society for Simulation in Healthcare 09/2011; 7(3):196-200. · 1.64 Impact Factor
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    ABSTRACT: Hemorrhage remains one of the most common causes of early death in severely injured patients. It is also the most common preventable cause of death in this population. More than 80% of deaths in the operating room and nearly 50% in the first 24 h after injury are related to hemorrhagic shock. Among the injured patients, up to 3-5% admitted to trauma centers will receive a massive transfusion (MT). This population may benefit from activation of MT protocols that are associated with decreased mortality and reduced overall blood transfusions. Using damage-control resuscitation and 1:1 ratios of blood components are associated with increased survival. However, the survival benefit of damage-control resuscitation and MT protocols is primarily in the first 24 h and is most impressive when these strategies are employed early. New scoring systems in conjunction with laboratory data have contributed to early objective identification of those patients requiring MT. Activating these protocols early and with an organized team approach is critical to achieving their full benefit.
    Expert Review of Hematology 04/2012; 5(2):211-8. · 2.38 Impact Factor
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    ABSTRACT: PURPOSE OF REVIEW: Early identification of shock and coagulopathy coupled with damage control resuscitation are central tenets of early trauma management. In traumatic injury, haemorrhage is responsible for almost 50% of deaths occurring within the first 24 h of injury and up to 80% of intraoperative trauma mortalities. Immediate haemorrhagic mortality constitutes the largest group of potentially preventable deaths in the initial 24-h period. This review will discuss the recent changes and advancement of early traumatic coagulopathy and the important role of substantial bleeding protocols (SBPs). RECENT FINDINGS: Ho et al. examined survivor bias and determined when accounting for survivor bias improved survival outcome with higher fresh frozen plasma: red blood cell ratios. The PROMMTT study, a 10-centre observation trial, highlighted the variable nature of infusion, the importance of time and improved outcomes with higher product ratios. SUMMARY: An SBP addresses the organizational issues necessary to respond to massive blood loss in an immediate and sustained manner. It reduces provider variability, facilitates staff communication and compliance, and simplifies the administration of predefined ratios of blood components. A transfusion subcommittee should be formed to directly address the complex issues of implementing a SBP system.
    Current opinion in anaesthesiology 02/2013;

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