In this episode we go back to the treatment of massive hemorrhage, not just trauma, but also OB with post-partum hemorrhage and GI bleeds. We touch on massive transfusion protocols and all the stuff that goes with them. We go over the Eight “Ts” of Massive Hemorrhage Protocols, with a special emphasis on rural centers. I am joined by returning guest:
Andew “Petro” Petrosoniak, MD
Andrew Petrosoniak, MD, MSc (MedEd), FRCPC is an Emergency Physician & Trauma Team Leader, Lead of the Translational Simulation & Clinical Integration at St. Michael’s Hospital, an Assistant Professor at the University of Toronto, an Associate Scientist at the Li Ka Shing Knowledge Institute and Co-Principal, Advanced Performance Healthcare Design. Find him on the web at: advancedperformance.ca or on the hellhole that is twitter at @petrosoniak.
Triggers
When to activate the MHP Delayed activation is OK. Default to 2–3 RBCs first, then reassess. Use “ABC after 3” approach.
RABT
Critical Administration Threshold
Shock Index
Intermediate Pack–what’s in it, no reason for all RBCs
[] 2022 study that shows no harm from early red
Obstetrics
Give us what you got
Team
Roles, leadership, communication Set resus targets early. Assign blood product flow to team members. Use shared mental models.
Doc on the transfuser
Transfuse Products
1:1 vs. 2:1
Shoot for 1:1
PLT
Fibrinogen
What is your transfusion trigger?
Blood Pressure Goal–adapt for transfer, for intubation. 80-90, 100 for head injury transfer intubation
Whole Blood–Petro doesn’t have it yet
Catch-Up PCC
Early PLT
Early Fibrinogen–is your need for fibrinogen based on a deficient FFP transfusion issue
Calcium
Vasopressin
GI Bleeds-AVB, not GI bleeding
Baveno VII
Crystalloid
Higher than trauma
Do not correct based on intial INR
Obstetric
Fibrinogen
REBOA
Rural Environment
Should we be stopping at rural hospitals?
Presented at AAST-FIRST2 Trial
After First 2 packs:
2000 U PCC and 4 G Fibrinogen Concentrate
May Repeat x 1 at the 30-60 minute mark if they are still there
Testing
Labs & frequency Hourly labs: CBC, INR, fibrinogen, ionized calcium, lactate. Don’t forget fibrinogen.
Q1 hour
POC
PT/PTT
TXA
Tranexamic acid use Trauma: 2g early. Time CutOff – they still use 3 hrs, I really want it in within 1 hour to 90 minutes
PPH: 1g then repeat.
GI: avoid—can cause harm.
Head Injury: Crash3 is ambiguous, Petro gives it, I do not
Temperature
Avoid hypothermia Warm blankets + prehospital warm-up.
Targets
Lab thresholds Hb >7, INR <1.8, Plt >50 (or >100 in ICH), Fibrinogen >1.5–2.
Termination
When to stop MHP
Reassess every 30 min.
Avoid premature deactivation. ICU vigilance post-MHP.
Additional New Information
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Editor-in-Chief, at EMCrit.org
An ED Intensivist from NY.
Professor
Nassau University Medical Center
No conflicts of interest (coi).
