Emergency red cells first: Rapid response or speed bump? The evolution of a massive transfusion protocol for trauma in a single UK centre

Boutefnouchet, Tarek; Gregg, Richard E.; Tidman, Jane; Isaac, John; Doughty, Heidi

doi:10.1016/j.injury.2015.05.046

Cited by 19 publications

(12 citation statements)

References 27 publications

Supporting

Mentioning

Contrasting

Unclassified

Order By: Relevance

“…Scores like TASH were developed to identify trauma patients at risk of massive transfusion based on data readily available on admission to the trauma centre, in order to justify an initiation of a massive transfusion protocol, even before coagulation measurements are available . A goal‐directed strategy implies monitoring by routine haematology, coagulation assays and viscoelastic tests before treatment, to allow identification of the significant number of patients who do not require RBC transfusion .…”

Section: Discussionmentioning

confidence: 99%

Change of transfusion and treatment paradigm in major trauma patients

et al. 2017

View full text Add to dashboard Cite

Trauma promotes trauma-induced coagulopathy, which requires urgent treatment with fixed-ratio transfusions of red blood cells, fresh frozen plasma and platelet concentrates, or goal-directed administration of coagulation factors based on viscoelastic testing. This retrospective observational study compared two time periods before (2005-2007) and after (2012-2014) the implementation of changes in trauma management protocols which included: use of goal-directed coagulation management; admission of patients to designated trauma centres; whole-body computed tomography scanning on admission; damage control surgery; permissive hypotension; restrictive fluid resuscitation; and administration of tranexamic acid. The incidence of massive transfusion (≥ 10 units of red blood cells from emergency department arrival until intensive care unit admission) was compared with the predicted incidence according to the trauma associated severe haemorrhage score. All adult (≥ 16 years) trauma patients primarily admitted to the University Hospital Zürich with an injury severity score ≥ 16 were included. In 2005-2007, the observed and trauma associated severe haemorrhage score that predicted the incidence of massive transfusion were identical, whereas in 2012-2014 the observed incidence was less than half that predicted (3.7% vs. 7.5%). Compared to 2005-2007, the proportion of patients transfused with red blood cells and fresh frozen plasma was significantly lower in 2012-2014 in both the emergency department (43% vs. 17%; 31% vs. 6%, respectively), and after 24 h (53% vs. 27%; 37% vs. 16%, respectively). The use of tranexamic acid and coagulation factor XIII also increased significantly in the 2012-2014 time period. Implementation of a revised trauma management strategy, which included goal-directed coagulation management, was associated with a reduced incidence of massive transfusion and a reduction in the transfusion of red blood cells and fresh frozen plasma.

show abstract

Section: Discussionmentioning

confidence: 99%

Change of transfusion and treatment paradigm in major trauma patients

et al. 2017

View full text Add to dashboard Cite

show abstract

“…Poor communication about the patient’s ongoing need for blood components has been shown to occur in up to one-third of cases [6], and difficulties in maintaining dynamic quantities of blood components in close proximity to patients that are moving through multiple hospital locations over a period of time can create potential issues. This suggests that there is room for improving closed loop communication between treating physicians and the lab, which may be enhanced through ongoing education and quality assurance initiatives [19-22]. Solutions to these problems could include regular meetings between treating services, encouraging physicians to collaborate via interprofessional grand rounds, and a multidisciplinary performance improvement group [20-21].…”

Section: Discussionmentioning

confidence: 99%

“…Differences in activation rates between the two specialty groups may not be surprising, as TACS may be more likely to rely on clinical gestalt than set activation criteria [16]. Further, MTP activation in non-trauma patients is highly variable, with estimations ranging from 8% - 50% of all MTPs [22]. Given that there is a lack of clinical research that has established objective criteria for activation of an MTP in non-trauma patients, specialists whose primary patient population are not treated in a trauma setting may be at a significant disadvantage, which may explain the disparity in activation between specialist groups.…”

Section: Discussionmentioning

confidence: 99%

Optimum Accuracy of Massive Transfusion Protocol Activation: The Clinician’s View

Bell

Prokopchuk‐Gauk

Cload

et al. 2018

Cureus

View full text Add to dashboard Cite

BackgroundMassive transfusion protocols (MTP) aid in the efficient delivery of blood components to rapidly exsanguinating patients. Unfortunately, clinical gestalt and currently available clinical scoring systems lack the optimal accuracy to prevent blood product wastage (through over-activation), as well as individual patient morbidity and mortality (through under-activation). In order to help refine the MTP activation criteria and protocols, we surveyed clinicians on acceptable over- and under-activation rates for massive transfusions.MethodsWe surveyed Canadian content experts in their respective fields, using a snowball survey technique. Respondents were categorized into two groups: Group 1 was comprised of trauma and acute care specialists (TACS), while Group 2 was comprised of clinical and laboratory medicine specialists (CLMS). Between-group differences were examined using Fisher’s exact test and the likelihood ratio. Statistical significance was set at p < 0.05.ResultsWe received responses from 35 clinicians in the TACS group and 10 clinicians in the CLMS group. About half (45.7%) of respondents in the TACS group considered an MTP overactivation rate of 5% - 10% acceptable (vs. 60% of the CLMS group; not significant (NS)). Approximately one-third (34.2%) of the respondents in the TACS group considered an MTP under-activation rate of less than 5% acceptable, whereas the majority (60%) of respondents in the CLMS group considered an under-activation rate of less than 5% acceptable (NS). A significantly greater proportion of respondents in the TACS group felt that an anticipated need for > 20 units of packed red blood cells within the next 24 hours was an acceptable criterion for MTP activation. Respondents in the CLMS group were more likely to consider “poor communication” as a reason for blood component wastage.ConclusionSimilarities in acceptable MTP over- and under-activation rates were noted across specialties. Collaboration between involved parties is necessary for MTP protocol development to improve patient outcomes and reduce blood wastage.

show abstract

“…Early blood transfusions may subsequently decrease the total amount of blood transfusion requirements per patient [ 13 ]. When considering poor outcomes observed among trauma patients with delayed blood transfusions during the initial resuscitation and among trauma patients receiving delayed excessive and unnecessary or futile blood transfusions [ 10 , 11 , 25 , 26 ], it is apparent that a strategy that balances the timely delivery of blood products produces improved patient outcomes [ 27 ]. Given limited on scene information, the intricate challenge for EMS personnel and physicians is to determine which specific patients require early blood transfusions in the prehospital setting.…”

Section: Discussionmentioning

confidence: 99%

A Derivation and Validation Study of an Early Blood Transfusion Needs Score for Severe Trauma Patients

et al. 2016

View full text Add to dashboard Cite

BackgroundThere is no existing adequate blood transfusion needs determination tool that Emergency Medical Services (EMS) personnel can use for prehospital blood transfusion initiation. In this study, a simple and pragmatic prehospital blood transfusion needs scoring system was derived and validated.MethodsLocal trauma registry data were reviewed retrospectively from 2004 through 2013. Patients were randomly assigned to derivation and validation cohorts. Multivariate logistic regression was used to identify the independent approachable risks associated with early blood transfusion needs in the derivation cohort in which a scoring system was derived. Sensitivity, specificity, and area under the receiver operational characteristic (AUC) were calculated and compared using both the derivation and validation data.ResultsA total of 24,303 patients were included with 12,151 patients in the derivation and 12,152 patients in the validation cohorts. Age, penetrating injury, heart rate, systolic blood pressure, and Glasgow coma scale (GCS) were risks predictive of early blood transfusion needs. An early blood transfusion needs score was derived. A score > 5 indicated risk of early blood transfusion need with a sensitivity of 83% and a specificity of 80%. A sensitivity of 82% and a specificity of 80% were also found in the validation study and their AUC showed no statistically significant difference (AUC of the derivation = 0.87 versus AUC of the validation = 0.86, P > 0.05).ConclusionsAn early blood transfusion scoring system was derived and internally validated to predict severe trauma patients requiring blood transfusion during prehospital or initial emergency department resuscitation.

show abstract

Emergency red cells first: Rapid response or speed bump? The evolution of a massive transfusion protocol for trauma in a single UK centre

Cited by 19 publications

References 27 publications

Change of transfusion and treatment paradigm in major trauma patients

Change of transfusion and treatment paradigm in major trauma patients

Optimum Accuracy of Massive Transfusion Protocol Activation: The Clinician’s View

A Derivation and Validation Study of an Early Blood Transfusion Needs Score for Severe Trauma Patients

Contact Info

Product

Resources

About