Elsevier

Critical Care Clinics

Volume 33, Issue 1, January 2017, Pages 71-84
Critical Care Clinics

Prediction of Massive Transfusion in Trauma

https://doi.org/10.1016/j.ccc.2016.08.002Get rights and content

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Key points

  • Damage control resuscitation with early activation of massive transfusion protocols improves the survival of the 25% or more of trauma patients who arrive with coagulopathy.

  • Using the traditional definition of massive transfusion of receiving 10 or more units of red blood cells in 24 hours introduces survival bias to resuscitation studies.

  • Use of contemporary concepts of substantial bleeding, resuscitation intensity, and critical administration threshold will improve the analysis of massive

Defining massive transfusion

Traditionally, MT has been defined as the transfusion of 10 or more units of RBCs within 24 hours of injury (Table 1). The origin of this definition is unclear, and although it is used commonly in both clinical and research realms, it has not been validated as a marker of bleeding severity. For example, a patient who receives 9 units of blood within a few hours who then progresses to either hemorrhage control or death, by this definition, has not had an MT despite clearly being in hemorrhagic

Isolated variables predicting transfusion needs

When assessing a severely injured patient, there are numerous physiologic, laboratory, and imaging variables that must be considered. Many of these provide information that can help predict whether a patient has substantial bleeding and requires MTP activation. Rapidly assessed clinical parameters, including hypotension, tachycardia, decreased mental status, and penetrating injury, individually predict MT need.21, 22, 23, 24 Laboratory values including base deficit (>5), elevated international

Clinical gestalt

To tackle the problem of information overload, physicians develop a clinical gestalt that they rely on for rapid decision making. After years of formal training, acquired knowledge, and tested experience, one uses pattern recognition and clinical reasoning to decide if a patient is in hemorrhagic shock and would benefit from MTP initiation. This raises the obvious question of how accurate is the clinical gestalt of an experienced trauma physician in predicting the need for an MT? As part of the

Assessment of Blood Consumption Score

The Assessment of Blood Consumption (ABC) score is a validated score, developed in a civilian setting in 2009.33 The investigators specifically set out to minimize any delay in initiation of their MTP, thereby focusing only on those variables available immediately after patient arrival. The ABC score relies on 4 nonweighted dichotomous parameters: penetrating mechanism, positive Focused Assessment with Sonography for Trauma (FAST), arrival systolic blood pressure (SBP) of 90 mm Hg or less, and

Prehospital prediction of massive transfusion

Scores used for MT prediction are designed to expedite the initiation of MTPs in DCR in an effort to decrease mortality. The earlier an MTP is initiated, the sooner products may be ordered and delivered to the bedside to be transfused. Can prehospital evaluation accurately predict the need for an MT so that MTPs can be initiated before a patient’s arrival? Weaver and colleagues45 developed a transfusion request policy whereby a caregiver in the prehospital setting can ask that an MT cooler is

Turning off massive transfusion

Deciding when to turn off an MTP is critical to prevent the misuse of both blood products and the efforts of blood bank staff. MTs account for more than 70% of blood transfused at trauma centers, and turning off these transfusions at an appropriate time minimizes the waste of this expensive and limited resource.48 The decision to stop an MT should be made jointly among all physicians active in the resuscitation team and should be communicated rapidly to the blood bank.49 Clearly MT should be

The use of massive transfusion scores in trauma trials

In order to perform high-quality prospective studies in this area, one must be able to accurately predict which patients will require an MT. Transfusion scores are becoming critical in determining which patients should be included, or excluded, from these trials. In their 2010 revalidation of the TASH score, the creators of the score concluded that although the clinical usefulness of this score remains questionable, it likely has tremendous research value.35 For example, in 2011, Borgman and

Summary

The traditional definition of an MT of 10 or more units of RBCs within 24 hours should be considered obsolete. It is now well recognized that the first 6 hours after a trauma are the most important for survival. Contemporary concepts such as Resuscitation Intensity and CAT emphasize the importance of transfusion rates rather than transfusion volumes. These terms allow us to treat, discuss, and study severely hemorrhaging patients with greater accuracy and precision. Their use minimizes survival

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  • Cited by (0)

    Disclaimer: Dr B.A. Cotton has served as a consultant for Haemonetics Corporation, Braintree, MA, makers of Thrombelastograph. Dr P.M. Cantle has no disclosures or conflicts.

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