Massive Transfusion Protocol

by Nikita Joshi MD  @njoshi8

The ambulance brought the patient to our expecting Emergency Department team. We moved him onto the stretcher and immediately placed stickers on his chest, connecting him to the cardiac monitor.The EMS team had already cut away his shirt, and from where I stood at the head of the bed, I could see the small dark hole in the left side of his chest. The pallor and coolness of his body told more than the hole itself. Our patient was dead. This young teenager died in those ambivalent early hours, no longer night, but still no hint of daybreak.. Shot to death on the streets, his heart was too far damaged to maintain his life with its pierced walls and chambers; the blood loss too great and too fast to replete. This young man bled out before he even reached the hospital; he had hemorrhaged to an early death.

This is one of the most common reasons people die from gunshot wounds: hemorrhage, or massive blood loss. Blood loss can be fast if an important or large artery, such as the aorta, is pierced. Blood loss can be slow and insidious, not revealing itself until it is too late, such as when the liver or spleen are bleeding. Regardless of its speed, if the bleeding is not discovered and stopped, the person will develop shock from the blood loss. The shock state will impact every organ in the body until they are all unable to keep up. The organs will eventually stop functioning, leading to death.

Emergency Medicine and Trauma Surgery healthcare providers are trained to recognize life threatening hemorrhage. Sometimes it is obvious, such as when the blood pumps out of the body from an arterial bleed. However, it may be very challenging to discover if the bleeding is internally contained, such as into the abdominal or chest cavity. Healthcare training teaches how the body behaves in the hemorrhagic state; clinicians learn to recognize abnormal vitals like a fast heart rate and a low blood pressure, or appreciate confusion as a sign of brain malfunction. Medical practitioners rely on vitals, the physical exam, and radiology such as CT scans and ultrasounds to identify and hopefully treat sources of life threatening bleeds.

One of the most important treatments for someone dying from hemorrhage is quick administration of blood. Usually when patients require blood transfusions, we prefer to give the blood type that matches the patient’s blood type. But, identifying the correct blood type takes precious time (sometimes hours), time that may not be available in a trauma resuscitation. In this setting, doctors will order something called a “Massive Transfusion Protocol” to safely and rapidly transfuse blood into the patient.

Ordering a Massive Transfusion Protocol triggers a cascade of events. The blood bank will release a large collection of blood products. Either this is already stored in the trauma resuscitation room or a technician retrieves the collection from the blood bank. Within the collection, there are packets of packed red blood cells (pRBCs), platelets, and fresh frozen plasma (FFP). The blood type provided is O Negative, which can be given to anyone regardless of their own blood type.

When someone bleeds, they lose not only highly valuable red blood cells, but also important components of blood including platelets and FFP. Platelets and FFP are critical in allowing the body to stop bleeding. Thus, it is imperative that the person who is shot receives platelets and clotting factors in addition to red blood cells. In a major trauma that causes life-threatening hemorrhage, the injured person is getting a massive, or very large, transfusion of pRBCs (blood), as well as units of platelets and FFP. There has been a lot of research and debate about the correct ratio of these three components and amount of transfusion that is most helpful to save a life. At the time of this writing, the, current thinking is that a 1:1:1 ratio is best. This means that the person will get 1 unit of pRBCs, platelets, and FFP with every cycle of transfusion. There may be many cycles administered during a resuscitation.

To facilitate the rapid infusion of blood products, the emergency medical team will place large intravenous catheters, or IVs into the arms of the person who has been shot. These large IVs – much larger than what is usually used in other medical settings – allow the blood to get into the body quickly. Even then, if the patient is not improving, the clinician may place an even larger IV, called a central venous catheter, into a large vein in the groin or neck area. This is performed if the person is worsening in the shock-state. This kind of catheter takes longer to place than a simple IV, but once placed, a central vein catheter can get more blood in the body faster.

A rapid infuser may be used to help pump the blood products into the injured person. This is equipment that the team is specially trained to use in a resuscitation setting. The team can place the blood, platelets, and FFP into the infuser to rapidly warm up, and then quickly tunnel through IV tubing into the person’s body.

What You Need to Know

  • It is critical to replace the lost blood and blood products in a person who is hemorrhaging
  • Sometimes it is obvious where the bleeding is coming from, but other times the source of blood loss may be difficult to identify. This makes reassessment of the injured person by the medical team very important.
  • Large IVs and rapid infuser equipment are important adjuncts to use when the person is hemorrhaging.

Where We Need More Research

  • We currently believe that 1:1:1 ratio of packed RBCs, platelets, and FFP is the best way to resuscitate the hemorrhaging patient, but more research is needed
  • We need more information on what medical therapies can and should be started in the prehospital setting, to save more lives after a gunshot wound. These questions are particularly important for victims of mass shootings.
  • We need to know more about the long-term consequences of massive transfusion on the people’s morbidity, mortality, and quality of life. This question is particularly important for patients with firearm injuries, as they are more likely to need a massive transfusion.

Nikita Joshi MD  @njoshi8