Cristy M. Thomas FNP-BCUniversity of Nevada School of

MedicineUniversity Medical Center, Las Vegas

NVNevada’s Only Level 1 Adult Trauma,

Level 2 Pediatric Trauma centers

30-40 percent of trauma deaths are secondary to exsanguination

Causes of Coagulopathy in Trauma Bleeding Fluid Resuscitation Transfusions-PRBC Hypothermia Multiple injuries

Hypothermia Acidosis Progressive Coagulopathy

Multifactoral Dilution Consumption of Platelets Coagulation factor dysfunction of coagulation

system

Partial thromboplastin time (PTT) Intrinsic Pathway

Prothrombin time (PT) Extrinsic Pathway

Thrombin time Common Pathway

Fresh frozen plasmaCryoprecipitateEpsilon-amino-caproic acid (Amicar)DDAVPRecombinant human factor VIIa (Novoseven)

SourcePlatelet concentrate (Random donor)

Each donor unit should increase platelet count ~10,000 /µlPheresis platelets (Single donor)

StorageUp to 5 days at room temperature

“Platelet trigger”Bone marrow suppressed patient (>10-20,000/µl)Bleeding/surgical patient (>50,000/µl)

Transfusion reactionsHigher incidence than in RBC transfusionsRelated to length of storage/leukocytes/RBC mismatchBacterial contamination

Platelet transfusion refractorinessAlloimmune destruction of platelets (HLA antigens)Non-immune refractoriness

Microangiopathic hemolytic anemiaCoagulopathySplenic sequestrationFever and infectionMedications (Amphotericin, vancomycin, ATG, Interferons)

Content - plasma (decreased factor V and VIII)Indications

Multiple coagulation deficiencies (liver disease, trauma)DICWarfarin reversalCoagulation deficiency (factor XI or VII)

Dose (225 ml/unit)10-15 ml/kg

NoteViral screened productABO compatible

Prepared from FFPContent

Factor VIII, von Willebrand factor, fibrinogen

IndicationsFibrinogen deficiencyUremiavon Willebrand disease

Dose (1 unit = 1 bag)1-2 units/10 kg body weight

MechanismPrevent activation plaminogen -> plasmin

Dose50mg/kg po or IV q 4 hr

UsesPrimary menorrhagiaOral bleedingBleeding in patients with thrombocytopeniaBlood loss during cardiac surgery

Side effectsGI toxicityThrombi formation

MechanismIncreased release of VWF from endothelium

Dose0.3µg/kg IV q12 hrs150mg intranasal q12hrs

UsesMost patients with von Willebrand diseaseMild hemophilia A

Side effectsFacial flushing and headacheWater retention and hyponatremia

MechanismActivates coagulation system through extrinsic pathway

Approved UseFactor VIII inhibitors in hemophiliacs

Dose: (1.2 mg/vial)90 µg/kg q 2 hr “Adjust as clinically indicated”

Cost (70 kg person) @ $1/µg~$5,000/dose or $60,000/day

Surgery or trauma with profuse bleedingConsider in patients with excessive bleeding without apparent surgical source and no response to other componentsDose: 50-100ug/kg for 1-2 dosesRisk of thrombotic complications not well defined

Anticoagulation therapy with bleeding20ug/kg with FFP if life or limb at risk; repeat if needed for bleeding

Journal of Emergency Medicine 2009 April Transfusion of Blood Products in Trauma: An

Update Massive Transfusion should be 1:1 Ratio Restrictive Transfusion Protocols Still in need of Prospective Randomized trials

to standardize protocols

Gonzalez et al. (2007) FFP should be given earlier to trauma patients requiring massive transfusions. Journal of Trauma. Jan 62(1) 112-119. Coagulopathies can be improved with strict

protocols 1:1 PRBC to FFP

Davis et al 2004 ICP monitor placement

157 patients in 3 groups INR 0.8-1.2 INR 1.3-1.6 INR>1.7

No difference in complications between the groups and INR correction with FFP only delayed monitor placement and treatment

Ilyas et al 2008 Earlier correction of INR with Factor VIIa

verses platelet transfusion 4 units vs 7 units of plasma Correction time was significantly

improved 2.4 hours vs 10 hrs

Williams et al 2008 Journal of Trauma Elderly patients classified as 50 and older INR >1.5 had a mortality rate of 22.6 %

vs 8.2% Suggestive of early monitoring and

correction or INR in anticoagulated patients 50 and older

Identify and correct any specific defect of hemostasis

Use non-transfusional drugs whenever possible

RBC transfusion for surgical procedures or large blood loss