Guidelines for Resource Utilization for Trauma and Severe Hemorrhage

Last update: March 20, 2020

In anticipation of blood product shortages due to precipitously decreasing donations (secondary to social distancing and self-quarantine practices in face of the COVID-19 pandemic), please consider the following recommendations in both trauma- and non-trauma-related hemorrhagic shock:

General considerations

• Hemorrhage source control remains the overall primary goal of hemorrhagic shock management, and will decrease overall utilization of blood products.
• Identify bleeding patients as early in their course as possible to avoid progression to advanced stages of shock.
• Literature clearly shows that excessive crystalloid use increases requirements for blood products and worsens coagulopathy, among other worsened outcomes.
• In general, TEG-guided transfusion strategies are associated with equivalent or better survival as well as improved resource utilization; transition from empiric to TEG-guided transfusion strategies as soon as practicable.
• Blood supply depends on on-going donation; encourage staff, patient family members, and the community at large to donate blood whenever possible.

Massive transfusion practices

At initiation of MTP:

• Obtain a rapid TEG.
• Administer 1g of TXA followed by 1g over 8 hours as a drip.

After 3 RBC / 3 FFP:

• Consider administration of 1500 units of 4-factor PCC if on-going hemorrhage.
• If FFP is unavailable, administer PCC earlier
• Consider administration of DDAVP (0.3mcg/kg IV or IM) to patients with low platelets, low MA on TEG, or empirically if on-going hemorrhage

After 6 RBC / 6 FFP:

• Ask the question: Is this patient salvageable? Will survival require on-going massive transfusion?
• Consult with another attending to discuss the case.
• Utilize rapid-response palliative care/ethics resources if time permits.

• Damage control packing
• Thrombin-containing topical hemostatic agents (Everest patch, FloSeal, thrombin-soaked gelfoam, etc.)

Reserve the use of generally scarce blood products such as platelets and cryoprecipitate to correct TEG derangements in actively bleeding patients only after use of adjuncts (such as DDAVP and PCC, etc.) have failed

Early use of vasopressin has been shown to decrease transfusion requirements; consider empiric vaso at a fixed rate of 0.04 mcg/kg in any patient requiring more than 2u of PRBC and 2u of FFP

Shed blood salvage processes

Intraoperative cell salvage

• CellSaver and other intraoperative cell salvage processes use a separate heparinized saline-irrigated suction system to trap blood from the field, which is subsequently washed and spun down into units of autologous RBC.
• Heparinized saline is used to prevent clotting during blood collection, but is >99.9% removed during the wash process.
• The autologous RBC produced have no formal storage anticoagulant, and must be used immediately.
• Optimal injuries for cell salvage have no gastrointestinal or urinary contamination; anecdotal data suggests that the salvage washing process is robust enough to remove clinically significant levels of contamination from blood contaminated with low levels of gastric, bilious, and urine contamination; salvage is not recommended for use in colon or small bowel contamination.
• Consider collecting potentially salvageable blood early in operative cases, and making the decision as to whether to wash and transfuse once the degree of contamination is more clear.

Chest tube autotransfusion

• Autotransfusion boxes can be placed in-line with chest tubes to collect blood in a ready-to-transfuse container.
• Pleural blood is known to be defibrinogenated (with INR measuring up to >9), but when diluted with normal plasma to maintain functional coagulation; therefore, transfusion is reasonable, particularly in combination with other blood products.
• Consider adding in-line autotransfusion collectors to any chest tube placed empirically during traumatic arrest, or for known or suspected hemothoraces.

Trauma scenarios 

Trauma patients with blunt injury and no identified source of hemorrhage (no external hemorrhage, negative CXR, negative eFAST exam)

• Practice permissive hypotension (MAP>50)
• Evaluate intravascular volume objectively (bedside IVC US, passive leg-raise test)
• Assess for other causes of hypotension (intoxication, etc.)
• Challenge with up to 1 liter of crystalloid
  • Responders: CT imaging
  • Non-responders: 1U emergency release RBC (from ED blood fridge) and reassess response; consider re-evaluating CXR/FAST

• Practice permissive hypotension (MAP>50)
• Obtain hemorrhage source control as early as possible:
  • Early preperitoneal pelvic packing with/without REBOA for severe pelvic fx
  • Low threshold (e.g. >2U RBC) to declare failure of nonoperative management for solid organ injuries

• If CPR <10 min:
  • Obtain definitive airway, perform bilateral finger thoracostomies, place at least one tibial IO if no existing IV access
  • Assess cardiac activity by ultrasound
    • If cardiac activity, evaluate for immediate operative hemorrhage control and transfuse 2U emergency release RBC (from ED blood fridge)
    • If no cardiac activity, abort resuscitative efforts without transfusion
  • Avoid repeated rounds of ACLS medications (epi/bicarb/calcium) if there is no clear reversible etiology for the arrest
• If CPR >10 min:
  • Assess cardiac activity by ultrasound
    • If cardiac activity, obtain definitive airway, perform bilateral finger thoracostomies, and transfuse 2U emergency release RBC (from ED blood fridge)
    • If no cardiac activity, abort without any further procedural interventions (to minimize the risk of COVID-19 exposure) and without transfusion (to conserve blood products)
  • Resuscitative thoracotomy should only be considered in cases of penetrating trauma with CPR <10min AND either clear cardiac tamponade on ultrasound or massive hemothorax on thoracostomy
• Resuscitative thoracotomy should not be performed in cases of GSW to head
• Resuscitative thoracotomy should not be performed in ANY blunt traumatic arrest

 Disclaimer

These documents and content on this website are guidelines during the COVID-19 pandemic. Because new information is released rapidly, these documents can be updated or changed at any time. These documents are in no way to be considered as a standard of care and the content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. The information in these documents is provided with no guarantees, accuracy, or timeliness. All content in these documents and website are for informational purposes only and do not constitute the providing of medical advice.