Upload
lecong
View
223
Download
5
Embed Size (px)
Citation preview
MASSIVEHAEMORRHAGEPOLICY
ABMUHBTransfusionTeam
Objec@ves
§ Todefinetheresponsibili@esandrolesoftheClinicalteamandtheHaematologyDepartmentinthemanagementof‘MASSIVEHAEMORRHAGE‘
§ Todescribetheprocessfordeliveringthetransfusion(includingprescribingandcheckingbloodproducts)
§ Toreviewuseoftranexamicacid
KeyPrinciplesremainthesameasothermajoracuteevent
communica@on
AppropriateAssessmentbyadoctor
Ac@vate
Delegaterole(teamleader)*
Implement
Pa@entAc@va@on/Review
communica@on
AppropriateReassessment
Con@nueorde-ac@vate
Nominatedleadchangesonpttransfer
Con@nueorde-ac@ve
REMEMBER!!TELLBLOODBANK
CriteriaforAc@va@on
• SystolicBP<90mmHgand/orpresenceofinadequate@ssueperfusion+evidenceofsignificantchest/abdomen/pelvic/longbonetrauma.• Caveats:children,elderly,co-morbidi@es.• Ideallybeforepa@entsarrives
Defini@onofongoingMassiveHaemorrhage
§ MassiveHaemorrhagemaybedefinedasthelossofonebloodvolumeovera24hourperiod.....
§ Orintheacutesitua@on.......§ 50%bloodvolumelossin3hours,Or
§ Bloodlossatarate>150mlperminute
Organisa@onandresponsibili@es
§ TheClinicalTeamLeaderdetermines‘MASSIVEHAEMORRHAGEsitua@on’
§ TheywillnominateateammemberwhowillcontactSwitchboard,givingdetailsof:Ø ClinicalareaØ Acontactname(teamleader)*Ø Contacttelephonenumber.
Tono4fy:§ Bloodtransfusionlaboratory(oroncallBMS)§ PorterSupervisor§ Relevantseniormedicalstaff§ ConsultantHaematologistoncallRelaytotheabove:Ø ClinicalAreaØ AcontactnameØ Contacttelephonenumber
RoleofSwitchboard
ClinicalResponsibili@esofteamleader/seniornurse
§ Ensurethepa@enthasauniqueiden@fierorNHSnumber
§ Ensurecorrectbloodsamplesandrequestformsaresentimmediately:
Ø FBC/biochemistryscreenØ GroupandsaveØ Coagula@onscreen
Informa@onrequirementsforpre-transfusiontes@ng–knownpa@ent
§ UniqueIden4fierHospital/NHS?/EDnumber
§ Lastname
§ Firstname
§ DateofbirthAgeisnotenough
§ AddressMinimumfirstline
§ RequesterIDSignatureofsampletakeranddateand4meofcollec4onINURGENTSITUATIONSINFORMATIONREQUIREMENTSARETHESAME
Informa@onrequirementsforpre-transfusiontes@ng–unknownpa@ent
• Hospital/EDnumber• LastnamestatedasUNKNOWN• Firstnameforexample:Male1/Female3• Indica@onofage–child,youngadult,elderly• The@meofadmission• Signatureofsampletaker
Responsibili@esoftheBloodTransfusionStaff
§ Thelabcontactsthenamedpersonintheclinicalareatoestablishpa@entcriteria.
§ ThelabassumesthattheemergencyORh(D)Nega@veunitsintheissuefridgehavebeentaken(unlessotherwisespecificallyno@fiedbytheassessingclinician)
§ Thelabwillissue:Ø Afurther4unitsofORh(D)Nega@veblood(ORh(D)posi@vedependingonavailability)
Ø 4unitsofFreshFrozenPlasma(FFP)willbeissued.
• NotallOnegBloodiswithoutrisk
• If @me allows and you are able to do agroupandsave(approx20mins) theLabwillbeabletoprovidebloodspecifics
The ultimate responsibility for use of any component lies with the Clinical Team/ Consultant Haematologist
SuitabilityofBlood
RoleofthePorters
§ Adedicatedporterwillbeiden@fiedandsenttothebloodtransfusionlaboratorytocollect:
Ø 4unitsofemergencyORh(D)[email protected]‘flyingsquadblood’
§ Theporterwillthen:Ø Collect4unitsofbloodand4FFP(MHP)Ø Delivergroupingbloodsamplesrequesttolab
Informa@onquality
Inadequatelylabelledsamplesandrequestformswillbediscarded
TransfusionDetails• BloodMUSTbewarmed.• Inshockedpa@entsBLOODisfirstlinetreatmentNOT
crystalloid.• Givebloodthroughthick/shortline(Traumaline).• Thetraumaleaderisresponsiblefor“standingdown”the
MHPandensuringthattheOnegbloodisbackinbloodbankin30minutes.
• CheckHaemoglobin,Potassium,CalciumandClonngaoertransfusionoffirstbloodseries
• Give10ml10%calciumchlorideaoerfirst4Ublood• MHPac@va@oncanoccuratany@meincludingbasedon
pre-hospitalvitals/mechanism
TRANEXAMICACIDINTRAUMA
Whatistranexamicacid?
• Itisanan@-fibrinoly@c• Fibrinprovidesthe‘skeleton’oftheclot• Plasmindegradesfibrin• Tranexamicacidstopstheac@va@onofplasminfromplasminogen
• Sotranexamicacid‘protects’theclot
Research
• CRASH2trialused>20,000pa@entsandfoundthat“allcausemortalitywassignificantlyreducedwithtranexamicacid.”
• “Riskofdeathfrombleedingsignificantlyreduced”
• Mainrisk:vascularocclusion(Myocardialinfarc@on,pulmonaryembolismandstroke)
Whyusetranexamicacid?
• Toreducetheriskofdeathduetobleedingintrauma.
• Itisusedinaddi@ontostandardresuscita@onandshouldnotbeusedasasubs@tuteforsurgicalinterven@ontocontrolbleeding.
• Purposeistostabilisetheclotinthecontextofdamagecontrolresuscita@on(keepthesystolicBPat90mmHg.)
Prescribing
• ConsultantormiddlegradedirectedbyTTL• 1gTranexamicacidIVbolus(maybegivenIO).FLUSHthelinebeforegivingblood
• Repeat(samedose)aoerEVERY10UnitsofBloodProducts(eg:6unitspackedredbloodcellsand4unitsFFP)
• Paediatricuseunprovenbutconsider• PaedsDosage:15mg/Kgtoamax1gover10mins
• ItiskeptintheTRAUMADRUGpack&drugcupboard
Indica@onsforuse
• Adulttraumapa@ent• Considerinchildren• Within8hoursofinjury• Significanthaemorrhage
– BP<90SYSTOLIC,PULSE>110– RISKOFSIGNIFICANTHAEMORRHAGE(COMPENSATEDSHOCKORRE-
BLEEDING)
Managementofhaemorrhage
• Damagecontrolresuscita@on• Primarysurveytheatre• Massivehaemorrhagepolicy• Tranexamicacid
FlowchartforMassiveHaemorrhageProtocolClinicalAreaTEAMLEADERMUSTDECLARE
MassiveHaemorhage-clinicalareaif:Clinicalevidenceofsuspectedmassivehaemorrhage
Nominated member of team 1. Generate emergency ID number for patient 2. Call switchboard – Notify massive haemorrhage-
clinical area and request Senior support 3. Send porter for ‘Emergency Blood’
4 units
SwitchboardsendoutMassiveHaemorrhage-clinicalarea-Alertbloodbankbyphone(day)orbleep(OOH),PortersLodge,
appropriateSpecialistConsultantandConsultantHaematologist
TakebaselinebloodsamplespriortotransfusionIncludingFBC,crossmatch,CloVngscreenandfibrinogenSendporterdirecttolabwithsamplesAndtocollectFFPx4plusONegRedcellsx4
ImmediateTransfusionGiveEmergency:• ONegredcellsx4units• 4unitsFFP• andfurther4ONegunitsredcells
Ifbleedingcon4nues–ContactlabtoinformofneedforongoingsupportSendportertocollect:• 4unitsredcell,groupspecific,• 4unitsFFP,• 1plateletpool,• Fibrinogenconcentrate4gms
• REPEATFBCANDCLOTTINGSCREENAdministerfurtherproductsif:
• Platelets<80x109/l–1poolplatelets(2if<30)• Fibrinogen<2.0g/l–4gmsfibrinogen
• APTT/PTra4o>1.5xnormal–6units(1.5litre)FFP
Immediateassessmentofcauseofbleedingandappropriatemanagement
Seniorreviewofmanagementplanand
appropriateinterven4ontoarrest
bleeding
Laboratoryprotocol:‘MassiveHaemorrhage’
CallforassistanceAssumeOnegused
Thaw4AFFPIssue4ONeg(emergencyuse)RestockemergencyONegEnsurePlateletsavailableCheckfibrinogenavailable
NinestepsforSuccessfulCo-ordina4oninMassivehaemorrhage(adults)
1. Recognisetriggerandac@vatepathwayformanagementofmassivehaemorrhage.
2. SendPorterfor‘Emergencyblood’4units.
3. Allocateteamroles.4. Completerequestforms/takeblood
samples-labelsamplescorrectly/re-checklabellingbeforedispatch.
5. Communica@onleadtobecontactedbyBMS(no@fiedbyswitchboard).
6. Requestbloodproducts.7. Effec@vecommunica@onbetweenthe
laboratoryandclinicalarea.8. CommunicateSTANDDOWNof
pathwaytoLaboratoryandPorters.9. Ensuredocumenta@oniscomplete.
LABBMSCONTACTMorristonExt3054duringcorehours(08.45-20.00&Saturday8.30-12.30)Bleep3914Outofhours(Saturday12.30-08.45Monday)BleepviaswitchboardifnoanswerSingletonExt5075duringcorehours(08.45–20.00&Saturday8.30-12.30)Bleep5716Outofhours(Saturday12.30-08.45Monday)BleepviaswitchboardifnoanswerPOW2585/2343Bleep253OOHNPT2367PORTERCONTACTSMorristonBleep3916Ext3098SingletonBleep5643Ext5372POWBleep270Ext2481Cisco6270NPTBleep2921Ext7750
REMEMBER ZERO TOLERANCE ON INADEQUATE LABELLING
IDENTIFIERS
SUMMARY.
• Criteriaforac@va@onofmassivehaemorrhagepolicy
• Rolesandresponsibili@es• ACCURATEIDENTIFICATION,COMMUNICATIONANDREVIEW
• Useoftranexamicacid