Sunday, December 30, 2012

Damage control resuscitation: The new transfusion ratios

Damage control resuscitation is a new concept born in the military setting and currently on ongoing implementation in the civilian setting also.

Trauma patients with life-threathening bleeding often develop or are at risk of developing the so-called "Lethal triad"(Acidosis, Hypothermia and Coagulopathy); correction of this features is of the paramount importance.

But which are our weapons in the fight to achieve this goal??!

Damage control resuscitation aim to hit at the hearth the mortal triple threat!!!
It consists of:
1-New trasfusion ratios
2-Permissive Hypotension
3-Active and passive warming
4-Factor VIIa
5-Exogenous buffer agents for acidosis temporization

Today i will address the new Trasfusion ratios:

Due to several years of experience in the two main war theaters: Afghanistan and Iraq, military surgeons have found that traditional approaches to resuscitation in terms of the ratio of blood products often fail to effectively treat the coagulopathy of massive bleeding casualties.
This observation has been concurrently noted in the civilian trauma literature

In the most of cases the traditional approach is as following:
Packed red blood cells(PRBC)/Fresh Frozen Plasma(FFP) ratio 3:1
Platelets usually infused after 10 U of PRBC.

Data pubblished by physician in theater showed improved patient survival when higher ratios of FFP and PRBC is achieved, plus the use of platelets.

Damage control resuscitation transfusion ratio:
early platelets before 10 U of PRBC transfused

Some military studies shows big benefits in terms of mortality with a trasfusion protocol:
PRBC/FFP/Platelets 1:1:1 

Very interesting a recent review about analysis of transfusion in Iraq and Afghanistan that showed not only that increase in survival was related with high transfusion ratios with FFP and Platelets but even that  Survival was most correlated with PLT ratio (Give a glimpse to references)

Just as a useful example i have attached the damage control resuscitation protocol (Image below) implemented by the UK defence medical services (in the references the pubmed link: the fulltext is for free).

Finally i found an other interesting pubblication from The Journal of Trauma (check references):
they found that high transfusion ratios with FFP and Platelets in patients not requiring massive transfusion don't increase Mortality but increase MORBIDITY so
beware because clinical assessment especially in the civilian setting is as always of utmost importance.

To Sum up:
Massive bleeding Trauma patient = Damage control resuscitation approach = 
High transfusion ratios PRBC/FFP/Platelets=
Early Platelets 

I hope this post was of interest, i'll write more in future about the other features of Damage control resuscitation;
 in the mean time,

Have a good day on the EDGE.

Haemorrhage and coagulopathy in the Defence Medical Services
Ten-year analysis of transfusion in Operation Iraqi Freedom and Operation Enduring Freedom: Increased plasma and platelet use correlates with improved survival.
Trends in trauma transfusion.
High ratios of plasma and platelets to packed red blood cells do not affect mortality in nonmassively transfused patients.
The contemporary role of blood products and components used in trauma resuscitation
Massive transfusion protocols for patients with substantial hemorrhage
Transfusion management of trauma patients.
Fresh frozen plasma should be given earlier to patients requiring massive transfusion.
The Armed Services Blood Program: Blood support to combat casualty care 2001 to 2011.
Damage control resuscitation: a sensible approach to the exsanguinating surgical patient.
Warm fresh whole blood transfusion for severe hemorrhage: U.S. military and potential civilian applications.
New developments in massive transfusion in trauma.


Saturday, December 29, 2012

Catastrophic Haemorrhage:the military approach; With the rising in the number and severity of gun-shot wounds could something be changed in the civilian setting also??!

ABC to <C>ABC: redefining the military trauma paradigm.

Tranexamic acid and Bleeding Trauma: the problem solver

This cheap and easy to use medication represent along with the Tourniquet one of the major breakthrough of the last years in the battle to reduce mortality in major bleeding traumas not only in the military setting but even in the civilian one.

Protocol of administration is very easy:

-Loud:1g in 100 ml Normal Saline 0,9% i.v. over 10 minutes NOT later than three  hours after injury.

-Mantainance: 1g diluited in 500 ml Normal Saline 0,9% i.v. over about 8 hours: 120 mg/h (60 ml/h).

CRASH2 study homepage
Tactical combat casualty care guidelines homepage
Military Application of Tranexamic Acid in Trauma Emergency Resuscitation (MATTERs) Study.
CRASH2 Design
CRASH2 results