Cristy M. Thomas FNP-BC University of Nevada School of Medicine University Medical Center, Las Vegas NV Nevada’s Only Level 1 Adult Trauma, Level 2 Pediatric Trauma centers

 percent of trauma deaths are secondary to exsanguination  Causes of Coagulopathy in Trauma  Bleeding  Fluid Resuscitation  Transfusions-PRBC  Hypothermia  Multiple injuries

 Hypothermia  Acidosis  Progressive Coagulopathy

 Multifactoral  Dilution  Consumption of Platelets  Coagulation factor dysfunction of coagulation system

 Partial thromboplastin time (PTT)  Intrinsic Pathway  Prothrombin time (PT)  Extrinsic Pathway  Thrombin time  Common Pathway

 Fresh frozen plasma  Cryoprecipitate  Epsilon-amino-caproic acid (Amicar)  DDAVP  Recombinant human factor VIIa (Novoseven)

Source Platelet concentrate (Random donor) Each donor unit should increase platelet count ~10,000 /µl Pheresis platelets (Single donor) Storage Up to 5 days at room temperature “Platelet trigger” Bone marrow suppressed patient (>10-20,000/µl) Bleeding/surgical patient (>50,000/µl)

Transfusion reactions Higher incidence than in RBC transfusions Related to length of storage/leukocytes/RBC mismatch Bacterial contamination Platelet transfusion refractoriness Alloimmune destruction of platelets (HLA antigens) Non-immune refractoriness Microangiopathic hemolytic anemia Coagulopathy Splenic sequestration Fever and infection Medications (Amphotericin, vancomycin, ATG, Interferons)

Content - plasma (decreased factor V and VIII) Indications Multiple coagulation deficiencies (liver disease, trauma) DIC Warfarin reversal Coagulation deficiency (factor XI or VII) Dose (225 ml/unit) ml/kg Note Viral screened product ABO compatible

Prepared from FFP Content Factor VIII, von Willebrand factor, fibrinogen Indications Fibrinogen deficiency Uremia von Willebrand disease Dose (1 unit = 1 bag) 1-2 units/10 kg body weight

Mechanism Prevent activation plaminogen -> plasmin Dose 50mg/kg po or IV q 4 hr Uses Primary menorrhagia Oral bleeding Bleeding in patients with thrombocytopenia Blood loss during cardiac surgery Side effects GI toxicity Thrombi formation

Mechanism Increased release of VWF from endothelium Dose 0.3µg/kg IV q12 hrs 150mg intranasal q12hrs Uses Most patients with von Willebrand disease Mild hemophilia A Side effects Facial flushing and headache Water retention and hyponatremia

Mechanism Activates coagulation system through extrinsic pathway Approved Use Factor VIII inhibitors in hemophiliacs Dose: (1.2 mg/vial) 90 µg/kg q 2 hr “Adjust as clinically indicated” Cost (70 kg $1/µg ~$5,000/dose or $60,000/day

Surgery or trauma with profuse bleeding Consider in patients with excessive bleeding without apparent surgical source and no response to other components Dose: ug/kg for 1-2 doses Risk of thrombotic complications not well defined Anticoagulation therapy with bleeding 20ug/kg with FFP if life or limb at risk; repeat if needed for bleeding

 Journal of Emergency Medicine 2009 April  Transfusion of Blood Products in Trauma: An Update  Massive Transfusion should be 1:1 Ratio  Restrictive Transfusion Protocols  Still in need of Prospective Randomized trials to standardize protocols

 Gonzalez et al. (2007) FFP should be given earlier to trauma patients requiring massive transfusions. Journal of Trauma. Jan 62(1)  Coagulopathies can be improved with strict protocols  1:1 PRBC to FFP

 Davis et al 2004  ICP monitor placement  157 patients in 3 groups  INR  INR  INR>1.7  No difference in complications between the groups and INR correction with FFP only delayed monitor placement and treatment

 Ilyas et al 2008  Earlier correction of INR with Factor VIIa verses platelet transfusion  4 units vs 7 units of plasma  Correction time was significantly improved  2.4 hours vs 10 hrs

 Williams et al 2008 Journal of Trauma  Elderly patients classified as 50 and older  INR >1.5 had a mortality rate of 22.6 % vs 8.2%  Suggestive of early monitoring and correction or INR in anticoagulated patients 50 and older

Identify and correct any specific defect of hemostasis Use non-transfusional drugs whenever possible RBC transfusion for surgical procedures or large blood loss