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Coagulation changes with massive haemorrhage (Damaged tissues release TF…
Coagulation changes with massive haemorrhage
Damaged tissues release TF
Minimisation
Initial measures to control haemorrhage and minimise trauma
Early surgical involvement and 'damage control' surgery
Consider interventional radiology depending on source
Consequences
Consumption of Plt and fibrinogen
Localised clotting
Localized activation of coagulation
Activation of protein C system from shock
Consequences
Impaired tissue perfusion = expression of thrombomodulin and protein C
Causes systemic anticoagulation
Minimisation
Early communication with haematologist, blood bank
Maintain cardiac output and tissue perfusion
Consideration of FVIIa 90mcg/kg when conventional measures have failed
Anaemia
Consequences
Inevitable consequence of bleeding
May also be dilutional from resuscitation with crystalloid/colloid
Decreased Hb and Hct
Minimisation
Avoid resus with crystalloid/colloid
Stop bleeding: conservative vs angio vs surgical
Red cell transfusion, target Hct 30 (number and size of RBC are factors in radial Plt transfer and adhesion to endothelium)
Haemodilution and consumptionof factors
Consequences
Crystalloid or colloid solutions
RBCs may be life saving but can dilute clotting factors and Plts and are independently associated with mortality and ARDS
Manifests as prolonged APTT, INR and PT
Individual factor levels low
TEG/ROTEM show slower +/- poorer clot formation
Minimisation
Use a massive transfusion protocol with ratio based transfusions
Move towards RBC:FFP:Plt of < 2:1:1
Avoid over resus with fluids initially
Aim INR <1.5
Tolerating relative hypotension initially to avoid dilution / clot stabilisation - accept SBP 90 (unless head trauma
Hyperfibrinolysis, consumption of plasminogen activator inhibitor
Consequences
Low fibrinogen
TEG or ROTEM may show hyperfibrinolysis
Minimisation
Maintain fibrinogen >1 (cryoprecipitate)
Tranexamic Acid early (CRASH 2 trial)
Thrombocytopenia
Consequences
May also have impaired function (TEG/ROTEM0
Low Plt count on FBE
Minimisation
Maintain Plt count with transfusion (ideally>75, gives buffer against main aim of maintaining count>50)
Acidaemia
Consequences
Tissue hypoxia/anaerobic metabolism and lactate production in setting of anaemia
Poor perfusion in setting of compromised cardiac output (hypovolaemia +/- obstruction related to trauma)
Minimisation
Optimise red cell mass
Minimise ongoing blood losses
Optimise patient's tolerance of anaemia: increase 02 delivery via fi02/Hb/CO and decrease demand e.g. paralysis
Bicarb previously used but no longer advised
Hypothermia
Consequences
Exposure to the elements
Infusion of cold fluid
Minimisation
Active fluid warming
Active patient warming (FAW)
Hypocalcaemia
Consequences
Consumption of Ca in clotting process
Transfusion of blood products containing citrate
Minimisation
Active measurement of Ca and replacement in ionised Ca < 0.9
Hyperkalaemia
Consequences
Occasional consequence of massive transfusion, esp in older blood (RPBCs)
Minimisation
Careful monitoring
Treatment as required
Ensure blood in date
Overview
Massive transfusion = transfusion of half blood volume in 4 hours or more than blood volume in 24 hours. In children, transfusion of >40ml/kg blood.
The changes in the patient will be dependent on the severity of trauma, time since injury and the amount of resuscitation measures already received.