Rachel HawesRVI
Northern trauma network conference
March 2014
Major Haemorrhage Policy for Trauma
Background
• Leading cause of traumatic death• Advances in haemostatic resuscitation• Balanced transfusion 1:1:1:1• Introduction of MHP
• Questions– How many major haemorrhage pt?– Frequency of Acute Coagulopathy of Trauma (ACoT)– How effective is our MHP?
RVI Major Haemorrhage Policy
• Standardise blood product use
• Reduce logistical delay
• Prehospital initiation • Pre-thawed FFP– avoid delay in receiving
balanced transfusion
Audit • Inclusions
– All trauma patients to RVI– April 2012 - April 2013– >18 yrs– Activation of MHP– Or >4 products in 1 hr
• Exclusions– Children– Preceding medical event– Transfers via Trauma Units
• Data Collection– Injury Severity Score (ISS)– TARN Predicted Survival– Actual 30 day mortality
– Presentation - Hb, PT, Fib– Products Transfused– Post MHP - Hb, PT, Fib
Results - How much trauma do we get?
• April 2012 - April 2013• 935 trauma calls• 899 TARN patients
– RTA– Assault– Fall
• Frequent of major haemorrhage?• 51 MHP Patients (5.6%)
Injury Severity Score v Mortality
Mortality - Standard Trauma Pt v MHP Pt
ISS versus Predicted & Actual Outcome
Coagulopathy
ACoT on Presentation in ED?
• Fibrinogen on presentation• Fibrinogen <1.5 = 21%
• PT on presentation• PT> 18 = 16%
Is ACoT due to Prehospital Fluid?
• No correlation between fluid volumes given and– Hb on presentation– PT on presentation– Fib on presentation
Presence of Coagulopathy Post MHP
• Post MHP Fib <1.5 = 0%• (Data for 33 Pt)
• Post MHP PT > 18 = 3%• (Data for 29 Pt)
Hb on Arrival v Post MHP
• Hb on arrival <8.0 = 6.8%
• Over and under transfusion
• Hb post MTP <8.0 = 5.8%
The Future
• Over and under transfusion– Deviation from policy– Timing of lab results– Lack of Point of Care testing - guide treatment
• Potential role of ROTEM/ TEG
• Prehospital Transfusion
Limitations
• Early deaths after presentation
• Unable to get bloods
• Included in ISS calculations but excluded for comparison of lab data
Summary• Trauma - Mortality proportional to ISS• 5% of patients have major haemorrhage• Increased mortality ass with major haemorrhage• 20% established ACoT on arrival
– Not related to prehospital fluid administration
• MHP effective in treatment and prevention of ACoT
• Future– POCT – TEG or ROTEM– ‘Blood on Board’ HEMS
Questions?