MASSIVE HEMORRHAGE PROTOCOLS: SMALL HOSPITALS · patients with either rapid blood loss or high risk of massive transfusion, e.g.: • WHO Grade 3 bleeding • Trauma ABC score ≥

MASSIVE HEMORRHAGE PROTOCOLS: SMALL HOSPITALSJACOB PENDERGRAST, MD, FRCPCBLOOD TRANSFUSION SERVICEUNIVERSITY HEALTH NETWORK

DISCLOSURES

Nothing to disclose

OBJECTIVES

1. Determine when to initiate patient transfer2. Consider how to make the most of limited

blood product inventory3. Discuss options for maintaining hemostatic

readiness

• ALL hospitals, no matter how small, must have a policy for “massive transfusion situations” (regulatory requirement)

• Patients will be transported from field directly to Lead Trauma Hospital (LTH) if high-risk injury (eg., physiologic, anatomic, mechanistic indicators, or important comorbidity)• LTH = Hamilton, Sudbury, Kingston, London, Ottawa,

Toronto, Windsor

1. Emergency Health Services Branch, MOHLTC, 2014 2. Altoijry, CMAJ Open 2016;4:E309

• However, if LTH > 30 minutes away by land ambulance, and land ambulance arrives on scene first, patient will be brought to the closest ER instead

VASCULAR TRAUMA INCIDENCE IN ONTARIO

When to Ship

• Ability to achieve source control of bleeding more important than hospital size in determining whether patient should be referred out

• If source control not available, immediately initiate transfer of patients with either rapid blood loss or high risk of massive transfusion, e.g.:• WHO Grade 3 bleeding• Trauma ABC score ≥ 2• High-risk pregnancy (4Ts)

• Make the call to ship as soon as you identify the need to ship!

When to Ship

• WHO Bellwether Procedures • Caesarean delivery• Laparotomy• Treatment of open fracture

• Hospitals that maintain capacity for the above three are likely to provide all essential surgical services

• However, only 16% of Ontario hospitals have capacity to treat vascular emergencies (Roche-Nagle, Vascular 2013;21:69)

When to Ship

• Society of Rural Physicians of Canada• Rural hospital: procedural care provided with ≤ 2 specialists

beyond a general surgeon• Rural area: average driving time under average-to-worst

case conditions (80 km/hr) is• > 1 hour to a Metropolitan Centre (tertiary care hospital with

medical school)• > 30 minutes to a Regional Centre

• In presence of major blood loss, patient transfer should be initiated immediately from above hospitals

Iglesias, Can J Rural Med 2006;11:207

Northern Ontario Hospital Catchement Areas (2006)

≥1 certified general surgeonnon- specialist surgical services availableno surgical services

Igle

sias

, Can

J R

ural

Med

200

6;11

:207

Timmins Cluster of Hospitals

Blood Product InventoryRBC (u) 32Plasma (u) 26Platelets (d) 1Cryo (u) 20Alb 25% 20Alb 5% 2PCC (500 u) 12RhIg (300 µg) 10HBIg (0.5 mL) 2VZIg (600 u) 2FVIII (500 u) 12FIX (500 u) 4aPCC (u) 3500IVIG (g) 100 C1Est (500 u) 3SCIg (g) 168Fibrinogen (g)Idarucizumab (5 g) 1

Timmins and District Hospital

IQMH

2007: 156 Ontario hospitals surveyed regarding their Massive Transfusion Protocols (MTP)• 22% routinely stocked platelets• 50% of labs routinely stocked cryoprecipitate• 70% indicated it would take more than an 1 hour to order

additional products from CBS• 22%: more than 6 hours

Stretching the Inventory

1. Be cautious in adopting ratio-based protocols which favour early use of platelets

• In absence of DIC or pre-existing thrombocytopenia, platelet count will not fall below critical threshold of 50 x 109/11 until patient has bled out over two blood volumes (> 20 units)1

• Remember that platelets sequestered in enlarged spleens (eg., cirrhotic patients) are still viable and will be released back into circulation with epinephrine surge2

• Recent MTP consensus conference advises against platelet transfusions to non-thrombocytopenic patients, even in setting of anti-platelet medications3

• Rural MDs generally report satisfaction with TAT of emergency lab testing4

1. Hippala, Anaesth Analges 1995;81:360 2. Aster, J Clin Invest 1966;45:645

3. Dzik, Crit Care 2011;15:2424. Carter, Can J Rural Med 2012;17:87


2. Develop redistribution networks with local hospitals • RBCs: small sites supply large sites• Platelets: large sites supply small sites• Have protocols and MOUs in place for

• Emergency transportation between hospitals (eg., OPP)• Shipping and receiving of products by clinicians (ie., sites

without 24 hr lab coverage)

TAHD

RBC (u) 32Plasma (u) 26Platelets (d) 1Cryo (u) 20Alb 25% 20Alb 5% 2PCC (500 u) 12RhIg (300 µg) 10HBIg (0.5 mL) 2VZIg (600 u) 2FVIII (500 u) 12FIX (500 u) 4aPCC (u) 3500IVIG (g) 100 C1Est (500 u) 3SCIg (g) 168Fibrinogen (g)Idarucizumab (5 g) 1

TAHD AGH LMH BMH SRF KL EDH SB ND HP

RBC (u) 32 4 6 2 2 18 2 8 8 4Plasma (u) 26 12 4Platelets (d) 1Cryo (u) 20Alb 25% 20 6 12 20 6 4Alb 5% 2 6PCC (500 u) 12 6 6 6 6 6 6 6 6 6RhIg (300 µg) 10 2 3 6 10 4 3HBIg (0.5 mL) 2 2 1VZIg (600 u) 2FVIII (500 u) 12 12FIX (500 u) 4aPCC (u) 3500 1000 1000IVIG (g) 100 C1Est (500 u) 3SCIg (g) 168Fibrinogen (g) 1 1Idarucizumab (5 g) 1

Only site with 24 hr operation Dispensary (no testing)

RBC Redistribution

HUB 1

HUB 2

Platelet Redistribution


3. Acceptable deviations during active hemorrhage• Drop irradiation requirement• Drop antigen-negative requirement• No ABO matching for cryoprecipitate• Substitute PCC+fibrinogen for plasma• Group A plasma for non-A recipients1

• Cold platelets2

• Emergency fresh whole blood collection3

1. Mehr, J Trauma Acute Care Surg 2013;74:1425 2. Milford, Transfusion 2016;56:S1403. Strandenes, Shock 2014;41(S1):76

Maximizing Hemostasis

1. Have all necessary anticoagulants antidotes locally stocked and protocolized

Anticoagulant AntidoteHeparin ProtamineWarfarin Vitamin K/PCCThrombolytic Fibrinogen concentrateDirect thrombin inhibitor (dabigatran)

Idarucizumab

Direct Xa inhibitor (rivatoxaban, apixaban)

PCC (off-label)


• Prescriptions for anticoagulants in rural Canada:• Result in equivalent rates of bleeding for patients on

warfarin1 but…• …are twice likely as urban areas to be inappropriate

for DOACs2

1. Tsadok, J Rural Health, 2015;31:3102. McAlister, J Am Health Assoc 2018 epub ahead of print

Maximizing hemostasis

• Survey of 103 low-volume ERs in Iowa• Although 40% had a warfarin-reversal protocol only 14%

stocked a 4-factor PCC• Only 2% had a DOAC-reversal protocol

Faine, Am J Health-Syst Pharm 2018;75:72


2. Incorporate pre-hospital RBC transfusion into MHP• Associated with increased survival when administered with

permissive hypotension (Rehn, Shock 2018 epub ahead of print) –definitive RCT underway

• However, may also be associated with higher risk of hypothermia upon hospital arrival if administered without portable blood warmer• Core temp of 34-36ºC associated with 16% increase in bleeding

(Meng, J Trauma 2003; 55:886)

• 2007: 62% of Ontario hospitals had a procedure for using a blood warmer

• 2016: 570 units of RBCs delivered by Ornge to 335 patients, predominantly in Northern Ontario


• Review of 703 patients transported by Helicopter to Level 1 Rural Trauma Centre in New England• 8.5% arrived with temp

< 35ºC• Risk increased if

transfused unwarmedRBCs en route, particularly during winter months

1. Wheeler, Air Med J, 2003;32:1


3. In rural/remote areas, tranexamic acid may also often need to be given in the field

• Review of 20 trauma HEMS transports in rural Alberta in which TXA was administered en route

• In majority of cases, waiting until patient arrival at hospital would have meant missing the 3 hour treatment window to start infusion

Mrochuk Air Med J 2015;34:1

• In absence of massive hemorrhage, giving 2 grams all at once may be reasonable alternative to CRASH-2 dose schedule


4. Maintain local capacity in compressive and topical hemostasis

• This is especially important when there is limited local capacity for surgical hemostasis

• Esophageal, gastric, uterine and aortic balloon tamponade (Blakemore /Linton Tube, Bakri Balloon, REBOA)

• Tourniquets and pelvic binders• Hemostatic gauze

Inconsistent/weak endorsement by professional guidelines.

However, observational studies suggest 80-90% effectiveness in treating atonic PPH refractory to medical management (ie., oxytocin, prostaglandins)

Low cost, low skill requirement, low complication rate

Rate of severe PPH in Canada is increasing

SUMMARY

• Basic Principles of Managing Massive Hemorrhage in Small Hospitals:• Initiate transfers early: Base decision to keep patient

primarily on local surgical capacity rather than hospital size• Transfuse judiciously: Be very selective with ratio-based

protocols; make efficient use of regional inventory while awaiting CBS deliveries/patient transfer

• Maintain non-surgical hemostatic readiness: Have resources in place for rapid anticoagulation reversal, treatment of hypothermia, administration of tranexamic acid, deployment of compressive hemostasis devices

THANK-YOU

TAHD

RBC (u) 32Plasma (u) 26Platelets (d) 1Cryo (u) 20Alb 25% 20Alb 5% 2PCC (500 u) 12RhIg (300 µg) 10HBIg (0.5 mL) 2VZIg (600 u) 2FVIII (500 u) 12FIX (500 u) 4aPCC (u) 3500IVIG (g) 100 C1Est (500 u) 3SCIg (g) 168Fibrinogen (g)Idarucizumab (5 g) 1

Documents

MASSIVE HEMORRHAGE PROTOCOLS: SMALL HOSPITALS · patients with either rapid blood loss or high risk of massive transfusion, e.g.: • WHO Grade 3 bleeding • Trauma ABC score ≥