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Massive Transfusion Protocol

Massive Transfusion Protocol: Considerations and rationale Massive transfusion protocol (MTP) is a tool used by clinicians when there is a need to rapidly administer a large amount of blood products, including packed red blood cells (pRBCs), fresh frozen plasma (FFP), and platelets. Complications of MTP are commonly referred to as “The Lethal Triad” referring to hypothermia, acidosis and coagulopathy. Authors: Kayleigh Yang Arzina Jaffer Reviewers: Jasleen Brar, Luiza Radu, Karl Darcus* * MD at time of publication Intervention Indications Initial Response Pathophysiology Transfusion Targets ≥ 3 pRBCs unit transfusion requirement in 1 hour Shock index (heart rate/systolic blood pressure) > 1 Blood volume loss >50% in ≤3 hours ABC Score ≥ 3 of: 1. Penetrating mechanism of injury 2. Systolic blood pressure < 90 mmHg 3. Heart rate > 120 beats per minute 4. Evidence of hemoperitoneum or hemopericardium on ultrasound (positive FAST U/S exam) RABT Score ≥ 2 of: 1. Penetrating mechanism of injury 2. Shock index > 1 3. Positive FAST U/S 4. Known or suspected pelvic fracture Call for help Activate institution's MTP protocol Send for STAT type and screen Establish large-bore intravenous access Fluid resuscitation Collect and send STAT bloodwork including hemoglobin, platelet, INR, fibrinogen, electrolytes, creatinine and arterial blood gas (ABG). Citrate present in blood products to avoid clotting during storage Stored pRBCs break down and release potassium due to time mediated degeneration Temporary accumulation of citrate in patient's blood with rapid use of blood products Citrate chelates calcium Less negative cell membrane resting potential Anaerobic metabolism Promotes hypocalcaemia Changes in membrane excitability Lactic acid buildup Coagulopathy (see coagulation cascade slide) Cardiac dysrhythmias (peaked T-waves, atrial block, “sine wave”, asystolic EKG changes) Metabolic acidosis End organ damage Continued blood loss Volume overload Avoid hypocalcemia Avoid hyperkalemia pH 7.35-7.45 Bleeding source control Hemoglobin >70-90 Platelets >50 INR <1.5 Fibrinogen >1.5 Avoid dilutional coagulopathy (clotting factor dilution) Mean Arterial Pressure (MAP) >60mmHg Temperature >35.0°C Slow (over 5-10 minutes) IV calcium administration Inhaled beta agonists Insulin/Dextrose EKG monitoring Sodium bicarbonate Increase minute ventilation Fastest control method to prevent further blood loss (i.e., packing wounds) Early tranexamic acid administration Administer pRBCs, FFP, and platelets in a 1:1:1 ratio (fibrinogen replacement indicated if <1.5 despite FFP) Minimize crystalloid use Administer crystalloids in a 3:1 ratio to estimated blood loss until blood products available Administer vasopressors to meet target, do not overshoot Temperature monitoring Fluid warming ↑ [Potassium] in pRBCs solution Administration of pRBCs ↑ potassium in patient's blood Blood loss ↓ Hemoglobin Tissue hypoperfusion Tissue hypoxia ↑ Diluent volume ↓ Concentration of clotting factors Tissue death ↓ Coagulation ability ↑ Transfusion requirements Early fluid resuscitation Rapid transfusion of cooled or room-temperature blood products/fluids ↑ Blood pressure Development of hypothermia ↑ Bleeding and clot dislodgement potential ↓ Enzyme activity in the coagulation cascade ↓ Coagulation ability Legend: Pathophysiology Mechanism Targets Intervention Published Sept 5, 2024 on www.thecalgaryguide.com