1. Trauma Resuscitations, Past, Present and Future Practices
Jennifer Middlekauff BSN, RN
Trauma Program Manager
The University of Kansas Hospital

2. I have nothing to disclose
6/3/2019

3. OBJECTIVES
Discuss the history of trauma resuscitation practices and it’s dependence on blood, blood products, and lab services for the care of our patients
Go over current practices of massive transfusion protocols, balanced resuscitation, and permissive hypotension
Learn about the “trauma triad of death” and how blood products are key components in current trauma resuscitations
Discuss current trends and future possibilities of trauma treatment in regards to whole blood, blood products and their use
6/3/2019

4. 6/3/2019

5. TRAUMA
According to the World Health Organization and the Centers for Disease Control
More than 9 people die every minute from injuries or violence
More than 5 million people die each year as a result of injuries
Motor Vehicle Crashes alone cause more than 1 million deaths annually and an estimated 20 million to 50 million significant injuries
By 2020 it is estimated that more than 1 in 10 people will die from injuries sustained in a trauma
6/3/2019

6. TRAUMA
The main cause of death for trauma patients, outside of the actual injuries, is hemorrhage.
Hemorrhage is the most common cause of death within the first hour of arrival to a trauma center
Over 80% of deaths in the OR and almost 50% of deaths in the first 24 hours after injury are due to exsanguination and coagulopathy
6/3/2019

7. “No matter what the case of trauma, the complex relationship between the injury and blood/fluid loss must be strategically organized to maintain optimal outcomes”
6/3/2019

8. History
1918: “Injection of a fluid that will increase blood pressure has dangers in itself. Hemorrhage in a case of shock may not have occurred to a marked degree because blood pressure has been too low and the flow too scant to overcome the obstacle offered by a clot”
“A hot drink should be given at the earliest moment”
“Not only does ordinary salt solution fail to combat acidosis, it actually increases an already existent acidosis.”
Cannon noted that there was an early hypercoagulable phase, followed by hypocoagulable phase. (100 years later this is a primary focus of trauma research)
6/3/2019

9. History 1930: Whole blood transfusions given during WWI and WWII
Field Blood Banks
1967: Shires et al. Fluid resuscitation following injury: Rationale for the use of Balanced Salt Solutions.
Giving us the concept of third-spacing. 1cc blood to 1cc of fluid
1994: Delayed aggressive fluid resuscitation until operative intervention improves the outcome in hypotensive patients with penetrating torso injuries.
2013: Multiple studies found by applying concept of trauma triad to decrease use of crystalloid and colloid fluids, better outcomes as patient were warmer, less acidotic, and euvolemic.
6/3/2019

10. 6/3/2019

11. Present 2019: Damage Control Resuscitation
Key concept adapted from military and wartime practices….1918 anyone?
DCR utilizes various methods to combat each component of the lethal triad
Tourniquets, Stop the Bleed,C-ABC
Warming methods
Minimizing crystalloids
MTP 1:1 or 1:2
6/3/2019

12. 6/3/2019

13. Present Massive Transfusion Protocols Tranexamic Acid (TXA)
What does your facility MTP look like?
Tranexamic Acid (TXA)
Thromboelastography (TEG)
6/3/2019

14. TEG
6/3/2019

15. Moving Forward
6/3/2019

16. Moving Forward WHOLE BLOOD
Used in every military conflict for the last 100 years
Moved away from in the civilian setting post Vietnam
Still utilized in military setting.
Walking Blood Bank (not FDA approved)
FDA: whole blood is indicated for symptomatic anemia with large volume deficits.
6/3/2019

17. Whole Blood vs Components
1 unit of each PRBC, FFP, PRBC, Plt, Cryo
Hct 29%, coagulation factors at 65% of normal, 80,000 plts, 1G fibrinogen, and a lot of citrate
1 unit of whole blood
38-50% Hct, coagulation factors at 100%, Plts at normal levels, 1G fibrinogen and a lot less citrate
Citrate- preservative necessary for increasing storage time for blood however binds to calcium
No concern for 1:1 resuscitations with whole blood
6/3/2019

18. Whole Blood Issues
WB has both cellular and antibody components making ABO compatibility challenging.
Waiting for appropriate blood typing tests increases mortality in a hemorrhaging patient
Storage time of 21 days (Cold Stored)
Mayo Clinic
University of Pittsburg
Statistical difference in mortality with whole blood vs component therapy…??
6/3/2019

19. Where Does That Leave Us?
Hemorrhage must be controlled
Whole blood with TEG driven component therapy
Continued research
6/3/2019

20. References
6/3/2019