1. “Running with the Bulls” Massive Transfusion in the ED
Dr. Samuel Minor
General Surgery
Critical Care Medicine
QEII Medical Director Trauma Program

2. Disclosure
No potential conflict

3. Staying Ahead of the Game

5. Trauma Outcomes Nova Scotia Trauma Program

6. The Lethal Triad

9. Trauma Induced Coagulopathy

11. Reperfusion Injury

13. Hemostatic Resuscitation
Limit crystalloid
Early identification of patients requiring massive transfusion
Warmed fluids
RBC:FFP:Platelets 1:1:1
Fibrinogen support >2g/L
TAX
Early use of mechanical hemostatic maneuvers
Pelvic binding
Scalp laceration
Tourniquet

16. Patient Selection for Massive Transfusion

18. Permissive Hypotension
Limit blood pressure to minimize bleeding
Decrease need for fluids/blood
Increase risk of reperfusion injury/tissue ischemia

19. Trauma In-Situ Simulation
“Crash Testing the Dummy”
Everything is real but the patient
Observe for:
Triage and management of life threatening injuries (“ABC”)
Measures to limit active bleeding
Pelvic binder
Suture/staple lacerations, tourniquet
Reduce fractures
Chest tubes
Early support of coagulation
Limit use of crystalloid
Activation of massive transfusion protocol
Early recognition for the need for operative intervention

20. FFP

22. Overall ratio of FFP:RBC did not change
Journal American College of Surgeons 2009
Introduced an MTP protocol that decreased the amount of time prior to transfusion of FFP
Overall ratio of FFP:RBC did not change
Overall number of blood products transfused did not change
Improvement of mortality 45%-19% (p=0.02)
Early administration of FFP is associated with improved mortality

23. Introduction of a MTP that made 6u pre-thawed AB FFP available
Effects of a hospital-wide introduction of a massive transfusion protocol on blood product ration and blood product waste J Emerg Trauma Shock Oct-Dec; 8(4):
Introduction of a MTP that made 6u pre-thawed AB FFP available
No difference in total amount of blood products transfused
Small increase in amount of FFP wastage
*50% reduction in wastage by increasing shelf life of FFP from 3 to 7 days

24. Summary Transfusion in the Trauma Bay is targeted to
Minimize reperfusion injury
Support coagulation
Balanced resuscitation decreases mortality
Unless pre-thawed FFP is available you will always be playing catch-up in trying to achieve 1:1:1