Hemorrhagic Shock

in the
TRAUMA patient
Rhyan Weaver, RN, BSN, CEN

Objectives
Review

the stages of hypovolemic

shock
Discuss

administration of autologous
blood and St. Josephs Trauma
Guidelines

Educate

about indications and

contraindications of tranexamic acid
(TXA) use

Classes of hypovolemic
shock
Class

I Hemorrhage

750ml
15% vol loss
VS normal
use crystalloid

Class

II Hemorrhage

750-1500ml
15-30% vol loss
100-120 bpm
decreased BP, use crystalloid

Classes of hypovolemic
shock
Class

III Hemorrhage

1500-2000ml
30-40% vol loss
120-140bpm
Hypotensive
give crystalloid + blood

Class

IV Hemorrhage

>2000ml
>40% vol loss
>140bpm
lethargic, no urine output
give crystalloid + blood

AUTOTRANSFUSION

http://www.thecentralline.com/?m=201008

http://www.atriummed.com

Autotransfusion
Collecting

and reinfusing patients own

blood
First

used in US in 1917

increased in mid 70s with more cardiac surgery

Research

increased due to potential to

eliminate:
Blood shortages
Infections
Transfusion-transmitted diseases

Trauma Indications
Emergency

chest trauma active bleeding

>300mls
Massive

hemothorax

Massive

non-contaminated
abd injury

Compatible
Religious

https://www.nlm.nih.gov/medlineplus/ency/presentations/10000
8_2.htm

blood not available

objections to banked blood

Contraindications
Coagulopathy
Pericardial,

or DIC

mediastinal, systemic

infections
Pulmonary/respiratory
Malignant

neoplasm

infection

Contraindications

continued

Contaminated

thoaco-abd cavities

Intraoperative

use of:

thrombin
hemostatic agents
iodine

Known

liver or renal dysfunction

Advantages
Immediate
Assured

blood replacement

compatibility

Compatible
Eliminates

temperature

some religious objections

Advantages
Eliminates

issues with rare blood

types
Cost

effective

Psychological
Decrease

reassurance to pt

chance of hypervolemia

Role of 2,3 DPG

High-energy

molecule in red cells

known as 2,3Diphosphyoglycerate

Lowers

HGB affinity for O2

Oxygen more readily released into

tissues

Role of 2,3 DPG

Banked

blood has very low levels (6%)

Autologous

blood may have up to 100%

Banked

blood = minimal O2 release to

tissues (initially)

pH

of autologous blood 7.4 banked

blood 6.3

Storage time
St.

Josephs trauma guidelines state

maximum time from collection to
autotransfusion = 4 hours

http://www.atriummed.com

Adverse Reactions
Coagulopathy

or DIC
Blood trauma/hemolysis
Sepsis
Air emboli (transfusion errors)
Citrate toxicity
Tingling around mouth
Stomach cramps
Myocardial depression
Arrhythmias
http://share.upmc.com/2015/03/blood-clots/

Equipment/Procedure
40-micron

blood filter in
addition to blood tubing

New

microemboli filter
for each ATS bag

Filter

http://www.terumocvgroup.com/products/ProductDetail.aspx?
groupId=1&familyID=26&country=1

+ entire tubing primed

with 0.9% NS

Equipment/Procedure
Spike

bag and open air vent

Pressure

infuser do NOT open air

vent
Max pressure is 150mmHg

DO

NOT infuse entire ATS bag

air emboli may result

ACD-A Citrate
Anticoagulant

Citrate Dextrose

Commonly called citrate

Must

be mixed with blood

during setup or during collection

Local

anticoagulant

Binds to Ca2+ ion

Prevents fibrinogen conversion to fibrin

ACD-A Citrate
Rapidly

metabolized by the liver

Helps

to preserve platelets

Helps

to eliminate filter clogging

The Arguments
Shed

hemothorax blood is not the

same as whole blood:
Laboratory tests show deficiency of Factor V
Oddly, hemothorax blood mixed with pooled plasma (in

lab) = increased coagulation

Concern for hypercoagulable condition

study by Dr. Rhee from UofA shows:

Hemothorax blood was given without complications

Reduced need for transfusions & hospital costs

Massive Transfusion Best

Practice
PROMMTT

study

PRospective Observational Multicenter Major Trauma Transfusion Study

Higher

plasma and platelet ratios early in

resuscitation = decreased mortality

Goal

for 1:1:1 transfusion ratio

Cryo

to be given with MTP at St. Josephs

Fibrinogen
Factor VIII
von Willebrand factor
Factor XIII

http://static.tti.tamu.edu

Massive Transfusion
Protocol
At

St. Josephs, indications for MTP

include:
Use of uncrossmatched blood
>4units PRBCs in first hour
Blood loss 150ml/min for >20 min (3000ml)
Loss of 50% volume in 1-3 hours
Loss of blood volume in 24 hours (>5000ml)

http://www.slideshare.net/DRSHADABKAMAL/massive-transfusionprotocol

Massive Transfusion
Protocol
After

activating MTP from blood bank you will

receive:
8 units PRBCs
8 units FFP
1 platelet pack (equivalent to 6-10 single donor units)
2 bags pooled cryoprecipitate (CRYO)

Additional

cycles are prepared in 1:1:1

ratio
(PRBC:FFP:Platelet)

Consider

persists

rFVIIa early if coagulopathic bleeding

Tranexamic Acid (TXA)

http://blog.clinicalmonster.com/2015/12/txa-intrauma/

http://www.webmd.com/drugs/2/drug-14044/tranexamic-acidintravenous/details

Antifibrinolytic
Anti-

bleeding drug

Inhibits

breakdown of clot by inhibiting

plasmin
Prevents breakdown of fibrin
Binds to lysine site on plasmin
Plasmin cant bind to clot and break it down

Also

thought to have anti-inflammatory

effect
Inhibits plasmin activation of complement system

CRASH-2 Study
Largest

TXA trial to date (Lancet, 2010)

Randomized control study

274 hospitals and 40 countries
20,211 patients
http://crash2.lshtm.ac.uk/

Given

early, demonstrated reduction of

bleeding

Decreased
No

mortality at 4 weeks

increase in thromboembolic events

MATTERs Study
Military

Application of TXA in Trauma

Emergency Resuscitation (JAMA, 2012)
Retrospective study in Afghanistan

300

received TXA; 600 did not

600 were

TXA

prior to CRASH-2 study

group had higher survival rates

despite being sicker patients (higher ISS)

TXA

group showed higher DVT rates

However, higher ISS and lived longer

Administration
Given

as 1gm IVP over 10min

Followed by infusion of another
1gm over 8 hours
Cost-effective
TIME

MATTERS

Best if given within first hour

NOT indicated after hour 3
May actually increase risk of death

Adverse Reactions
GI

disturbances

Mild n/v, diarrhea

Blurry

vision

Rare symptom

Seizures
Seen in trials with very high doses

Hypotension
If pushed too quickly IV

http://www.webmd.com/epilepsy/guide/types-of-seizures-theirsymptoms

Contraindications
Hypersensitivity
TBI

specifically SAH

Can cause secondary ischemic injury

Ongoing trial at Barrow for TXA in traumatic SDH
not currently indicated for TBI

DIC
Hypercoagulable

states

References
American

College of Surgeons Committee on Trauma. (2012). Advanced trauma life support: Student course manual. (9th ed.). Chicago, IL: American College
of Surgeons.

Atrium

Medical Corporation. (2004). A personal guide to managing chest drainage autotransfusion. Hudson, NH: Atrium Medical Corporation. Retrieved
fromhttp://www.atriummed.com/PDF/Red%20Handbook.pdf

Binz,

S., McCollester, J., Thomas, S., Miller, J., Pohlman, T., Waxman, D. et al. (2015).CRASH-2 study of tranexamic acid to treat bleeding in trauma patients: A
controversy fueled by science and social media. Journal of Blood Transfusion, 2015, 1-12.http://dx.doi.org.ezproxy1.lib.asu.edu/10.1155/2015/874920

Caliste,

X.A., McArthur, K.A., & Sava, J.A. (2014). Autotransfusion in emergent operative trauma resuscitation. European Journal of Trauma and Emergency
Surgery, 40, 541-545.

Ferrosan

Medical Devices. (2010). Coagulation cascade. Retrieved fromhttps://www.youtube.com/watch?v=xNZEERMSeyM

Harrison,

H.B., Smith, W.Z., Salhanick, M.A., Higgins, R.A., Ortiz, A., Olson, J.D. et al. (2014). An experimental model of hemothorax autotransfusion: impact on
coagulation. The American Journal of Surgery, 208, 1078-1082.

Kuklinski,

J. (2015). Tranexamic acid. LVHN MedEvac Education Channel. Retrieved fromhttps://www.youtube.com/watch?v=sjmhFmWQXwQ

McCormack,

P.L. (2012). Tranexamic Acid: A review of its use in the treatment of hyperfibrinolysis. Drugs, 72, 582-617. doi: 10.2165/11209070-000000000-

00000
Reed,

M.R. & Woolley, T. (2014). Uses of tranexamic acid. Continuing Education in Anaesthesia, Critical Care & Pain, 15, 32-37. doi:
10.1093/bjaceaccp/mku009

Rhee,

P., Inaba, K., Pandit, V., Khalil, M., Siboni, S., Vercrusse, G. et al. (2015). Early autologous fresh whole blood transfusion leads to less allogeneic
transfusions and is safe. Journal of Trauma and Acute Care Surgery, 78, 729-734.

Smith,

W.Z., Harrison, H.B., Salhanick, M.A., Higgins, R.A., Ortiz, A., Olson, J.D. et al. (2013).A small amount can make a difference: a prospective human study
of the paradoxical coagulation characteristics of hemothorax. The American Journal of Surgery, 206, 904-910.

Trauma

Administration. (2013). Massive transfusion protocol in Practice management guideline. Unpublished internal document, St. Josephs Hospital and
Medical Center.

Trauma

Administration. (2013). Trauma room autotransfusion in Trauma guideline. Unpublished internal document, St. Josephs Hospital and Medical Center