1. Transfusing tiny soldiers Ramsey C. Tate, MD

2. Applying combat-derived massive transfusion protocols to pediatric trauma patients

3. Case Damage control resuscitation Massive transfusion protocols Pediatric massive transfusion protocols Agenda

4. Case Damage control resuscitation (DCR) Massive transfusion protocols (MTP) Pediatric massive transfusion protocols Agenda

6. GCS 15 HR 151 BP 100/palp

7. HR 166 BP 60/palp “exhibits transient loss of consciousness”

8. Trauma code Emergently taken to OR “Likely to require multiple transfusions” Grade V liver laceration

9. Packed red blood cells:19 units Fresh frozen plasma: 5 units Apheresis platelets: 1 units Cryoprecipitate pooled: 2 units Recombinant Factor VIIa: 1 dose

12. 5 million

13. 40 % Massive hemorrhage carries greater than 50% risk of death

14. Damage Control Resuscitation

15. Permissive hypotension Aggressive correction of coagulopathy Use of vasopressors and blood products to maintain hemodynamics and euvolemia

16. Damage Control Resuscitation Permissive hypotension Aggressive correction of coagulopathy Use of vasopressors and blood products to maintain hemodynamics and euvolemia Hemostatic resuscitation

17. Death Damage Control Resuscitation Acidosis Hypothermia Coagulopathy

18. Death Damage Control Resuscitation AcidosisHypothermia Coagulopathy

19. Death Damage Control Resuscitation AcidosisHypothermia Coagulopathy Early trauma induced coagulopathy Dilutional coagulopathy

20. 3% of adult civilian trauma patients

21. 70% of transfused blood products at trauma centers

22. Transfusion of more than 10 units of blood Loss of 50% of blood volume in 3 hours Ongoing blood loss of 150 mL/hour

23. 5 liters 0.5 liters

24. 5 liters 0.5 liters Transfusion of one blood volume in 24 hours

25. Approaches to massive transfusion Component therapy Transfusion physician management Massive transfusion protocol with predetermined blood product administration

27. Fresh whole blood: 500 mL Hct 33-43% Plt 130- 350,000 Fibrinogen 1500 mg Clotting activity 86% Full platelet activity Warm

28. Fresh whole blood: 500 mL Hct 33-43% Plt 130- 350,000 Fibrinogen 1500 mg Clotting activity 86% Full platelet activity Warm RBC + Platelets + FFP: 660 mL Hct 29% Plt 88,000 Fibrinogen 750 mg Clotting activity 65% Reduced platelet activity Cold

29. Fresh whole blood: 500 mL Hct 33-43% Plt 130- 350,000 Fibrinogen 1500 mg Clotting activity 86% Full platelet activity Warm RBC + Platelets + FFP: 660 mL Hct 29% Plt 88,000 Fibrinogen 750 mg Clotting activity 65% Reduced platelet activity Cold 1:1: 1

30. Key components of MTP Resuscitation with predetermined ratios of blood components Rapid infusion of warmed blood products Coordination with transfusion specialists to ensure streamlined delivery of products Monitoring of coagulation studies to determine the end-point of protocol

31. Key components of MTP Resuscitation with predetermined ratios of blood components 1 RBC:1 FFP:1 Platelet Rapid infusion of warmed blood products Coordination with transfusion specialists to ensure streamlined delivery of products Monitoring of coagulation studies to determine the end-point of protocol

32. Key components of MTP Resuscitation with predetermined ratios of blood components Rapid infusion of warmed blood products Coordination with transfusion specialists to ensure streamlined delivery of products Monitoring of coagulation studies to determine the end-point of protocol

33. Key components of MTP Resuscitation with predetermined ratios of blood components Rapid infusion of warmed blood products Coordination with transfusion specialists to ensure streamlined delivery of products Monitoring of coagulation studies to determine the end-point of protocol

34. Key components of MTP Resuscitation with predetermined ratios of blood components Rapid infusion of warmed blood products Coordination with transfusion specialists to ensure streamlined delivery of products Monitoring of coagulation studies to determine the end-point of protocol

35. MTP-associated outcomes Mortality Decreases in blood product consumption Improvements in blood product delivery Decreases in ventilator-associated pneumonia Decreases in open abdomen days and abdominal compartment syndrome

36. MTP-associated outcomes Mortality Decreases in blood product consumption Improvements in blood product delivery Decreases in ventilator-associated pneumonia Decreases in open abdomen days and abdominal compartment syndrome All published data are retrospective!

38. Paterson, 2009 Case report: Pre-surgical planning for 5 yo with ruptured AVM

39. Paterson, 2009 Case report: Pre-surgical planning for 5 yo with ruptured AVM This might work in the OR…

40. … but tough to do in here.

41. Dehmer and Adamson, 2010 Expert opinion: Adapted Paterson’s protocol

42. Harborview pediatric MTP adapted by Brian Johnston

43. On the horizon Pediatric MTP in development at UNM

44. On the horizon Pediatric MTP in development at UNM Introduction of ROTEM testing

45. On the horizon Pediatric MTP in development at UNM Introduction of ROTEM testing PROMMTT Study

46. Questions?