Massive Haemorrhage

Definitions
• Loss of entire blood volume equivalent within 24hrs
• Loss of 50% of blood volume within 3hrs
• Continuing blood loss of 150ml/min
• Continuing blood loss of 1.5ml/kg/min over 20 min

• Rapid blood loss leading to decompensation and circulatory failure

despite volume replacement and interventional treatment
Lethal triad: Bloody vicious cycle
 Factors contributing to the Coagulopathy
of Trauma
Acidosis
• Decrease coagulation factor activity
thrombin generation
platelet aggregation

• Enhanced fibrinolysis via increased tPa and

depletion of plasma activator inhibitor-1

• Hypoxia and anaerobic metabolism

 Factors contributing to the Coagulopathy
of Trauma
Hypothermia
• Platelet dysfunction
• Reduced clotting factor activity

Dilutional Coagulopathy
• Factor deficiency
• Thrombocytopenia
• Anaemia
 Factors contributing to the Coagulopathy
of Trauma
Consumption of
• Platelets
• Fibrinogen
• Clotting factors

Crit Care Med 2008 Vol 36, No 7 (Suppl.)

Prevent Coagulopathy
The aim: Prevent the Coagulopathy
• The lethal triad
• Appropriate choices of resuscitation fluids
• The amounts and ratio of these products to
one another
• The timing of delivery of these products
• The use of adjuncts to resuscitation
(recombinant Factor VIIa)
 Permissive Hypotension
• Allowing the BP of the patient who has the
risk of major ongoing bleeding to not return
to normal values,
• But to stabilise at values around 75% of
normal until surgical control of bleeding is
established
• Prevention of rebleeding syndrome
 Contra-indications
Use normal rules for Resuscitation:

• Haemodinamically stable patient

• Prior to exclusion of Obstructive Shock
• Compressible bleed from isolated / external wounds
• Major head trauma
• Pregnant and childhood –no data yet
• Burns
• Possible crush syndrome / prolonged entrapment
 Criteria to achieve
• Perfusion not pressure
• Urine output
• Lactate < 5 mmol/l
• Rousable patient

• Palpable radial pulse

• SBP +/- 80mmHg
 Massive Transfusion

• Many trauma centres have their own protocols:

• i.) Massive blood loss with profound haemorrhage / hypovolemic shock
Adult pts who require >10 U
• ii.) Continued bleeding after transfusion of 5 u in 4hrs / 10u in 24hrs
• Iii.) Prolonged PT, Depressed Fibrinogen => DIC

• Intended to: Rapid restore blood volume

Prevent coagulopathy
• PRBC/FFP/Platelet ratio 1:1:1
 Massive
Transfusion
Blood Component therapy
 Fresh Whole Blood
• Key question driving current resuscitation
research
• ‘What is the optimal resuscitation fluid for a
severely injured trauma patient?’
• Simplest answer: ‘Give the patient back the
fresh whole blood that he lost’
 Reality more complex
• Modern experience with FWB is small

Animal studies:
• Restores myocardial function better than PRBC
• Best 24hr hypotensive resuscitation fluid

US Army survival benefit

• Analysis is ongoing

Problem: Cost
Safety
Mimic delivery of whole blood 1:1:1
rFVIIa enhances platelet thrombin
generation
 rFVIIa
• Considerable debate
• Timing
• Selection of patients

• Less effective in acidosis

• Remains effective in all but most severely hypothermic settings

• Theoretical risk of thrombo-embolic events must be balanced against the more acute risk of
exsanguination
- Less than 0.05% of serious events in >480 000 doses given to pts with haemophilia
- >1000 pts with haemophilia no statistically significant difference in events vs placebo group

• Current limitations: Storage 2’C - 8’C

Short t1/2
High cost
• Require completion of ungoing trails
 References:
An approach to transfusion and hemmorrhage in trauma: current prospectives on restrictive transfusion
strategies.
Tien H et al Can J Surg. 2007 Jun;50(3):202-9
Prehospital advances in management of severe penetrating trauma.
Robert Mabray Crit Care Med 2008 Jul;36(7 Suppl)S258-66
Exsanguination in trauma: A review of diagnostic and treatment options
Geeraedts et al Injury 2009 Jan;40(1):11-20 Epub 2009 Jan 8
The cellular basis of traumatic bleeding
Hoffman M. Mil Med. 2004 Dec;196(12Suppl):5-7,4
Monitoring of Hemostasis in combat trauma patients
Carr ME Jr. Mil Med. 2004 Dec;169(12 Suppl):11-5,4
Massive transfusion and nonsurgical hemostatic agents
Perkins JG et al Crit Care Med 2008 Jul;36(7 Suppl):S325-39
Warm fresh whole blood transfusion for severe hemorrhage
Spinella PC Crit Care Med 2008 Jul;36(7 Suppl):S340-5
Damage control resuscitation: a sensible approach to the exsanguinating surgical patient
Beekley AC Crit Care Med 2008 Jul;36(7 Suppl):S267-74
Are we giving enough coagulation factors during major trauma resuscitation?
Ho AM et al. Am J Surg. 2005 Sep;190(3):479-84
 References:
• Transfusion practice in military trauma.
Hess JR Transfus Med. 2008 Jun;18(3):143-50
• Are we giving enough coagulation factors during major trauma resuscitation?
Anthony M Am J of Surg 2005 190:479-484
• Transfusion of Blood Products in trauma: an update
Fraga J of Emerg Med 2009.02.034
• Effect of recombinant factor VIIa as an adjunctive therapy in damage control
Fox et al J Trauma 2009 Apr; 66(4 Suppl):S112-9

Talks:
- Prof / Colonel Tim Hodgets
<C>ABC
Emergency Medicine in the developing world, Cape Town 2007
- Tim Hardcastle
Fluids in Pre-hospital cases
Emergency Medicine in the developing world, Cape Town 2007