trauma resuscitation mtp

stage 1

Permissive hypotension

  • permissive hypotension is ok for penetrative (not blunt, normotension) torso trauma in ED: 70/palpable is ok. NNT 12

  • permissive hypotension in OR with MAP 50 terminated earlier due to cannot get MAP separated between 2 groups

MTP

  • MTP: original def 10u/24hrs

  • 3u prbc in 1 hr

  • in the past: BP, UOP
  • today: prevent coagulopathy, AKI, ARDS, consequence of reperfusion

  • new: RH+ whole blood for pregnant women as well
  • leukocyte reduced
  • low titer O blood: low anti A / B levels
  • whole blood: 500 cc

  • 24h consumption less
  • uses more upfront

  • blunt/penetrating trauma are very different

Stage 2

plasma and pletelet

  • bleeding fraction: how much original blood left
  • higher INR = higher mortality. Lineaer relationship

  • big study
  • balanced blood products in first 6 hours leads to best outcome. TEG can be used after 6 hrs

  • very big study

Combat:

  • secondary analysis showed whole blood did better
  • 2 reasons switched to component:
  • easier to store component therapy
  • whole blood: can make more money with different components
  • severe TBI excluded
  • massive improvement with whole blood
  • trauma bay mortality not really helpful
  • no real data to support whole blood being better

  • odds survival much better in whole blood
  • still not convincing

  • current trial

PCC

  • AKA Kcentra
  • 1 dose 2,000u
  • FFP with PCC better
  • no difference in mortality
  • difference in VTE

Current trial:

When to activate MTP

  • first 2: needs labs
  • FFP: liquid plasma is used more at Wake (can return)
  • not really used anymore
  • plt: aphresis. Here 1:1:1 at Wake.
  • vasopressin for MTP? AVERT trial