Severe Bleeding Max Marsden

Question 1

What antibodies are in the plasma of a group A B AB and O patient

Answer 1

A - anti B
b - anti A
AB - none
O - anti a + anti b

Question 2

What were the first blood groupings called

Answer 2

A b c

Question 3

When was the first wartime transfusion

Answer 3

Oct 1915
Lawrence Robertson performed w a syringe to a pt w multiple shrapnel wounds

Question 4

Lethal trias

Answer 4

Acidosis
Hypothermia
Coagulopathy

Question 5

What did borgman 2007 investigate and what did he find

Answer 5

Investigated 1:8 vs 1:2.5 vs 1:1.4 plasma:RBC ratio blood products and their effects on mortality according
Lower mortality in higher RBC:plasma ratio

Question 6

PROMMTT trial 2013

Answer 6

Prospective observational multicentre major trauma transfusion
Higher plasma:RBC and platelet:RBC assoc w lower 6 hour mortality

Question 7

PROPPR trial

Answer 7

Prospective randomised optimum platelet and plasma ratios
Compared plasma platelet and RBC transfusion in a 1:1:1 and 1:1:2 ratio
No difference

Question 8

TROOP trial

Answer 8

Trauma resuscitation with group o whole blood or products
Low titre group o whole blood vs standard therapy in critically injured patients requiring large volume transfusion

Question 9

SWiFT trial

Answer 9

Study of whole blood in frontline trauma
PH whole blood transfuasion vs standard therapy for clinical and cost effectiveness

Question 10

REPHILL

Answer 10

Resuscitation with pre hospital blood products
No effectively

Question 11

Did plasma increase or decrease 30 day mortality compared to standard resuscitation in a 2018 trial with patients at risk for Haemorrhagic shock

Answer 11

Decrease

Question 12

When does prehospital plasma have a survival benefit

Answer 12

When transport times are longer than 20 mins

Question 13

Primary outcomes of REPHIL

Answer 13

Lactate clearance
Episode mortality

Question 14

Swift intervention and control

Answer 14

Intervention 2 units whole blood
Control 2 units RBC + 2 units plasma

Question 15

Main cause of preventable death after injury

Answer 15

Bleeding

Question 16

Shock

Answer 16

Inadequate oxygen delivery at the cellular level

Question 17

Haemorrhagic shock

Answer 17

Severe blood loss leads to inadequate oxygen delivery at the cellular level

Question 18

Cellular level pathophysiological of Haemorrhagic shock

Answer 18

Insufficient o2 delivery -> anaerobic metabolism
incr lactic acid, phosphates, and o2 radicals
DAMPs release -> systemic inflam
Decr ATP -> cell necrosis

Question 19

DAMPs

Answer 19

Damage associated molecular patterns
Mitochondrial DNA, formyl peptides

Question 20

Tissue level pathophysiology of Haemorrhagic shock

Answer 20

Hypovol and vasocontriction -> hypoperfusion
End organ damage
Multiorgan failure in survivors
Hypoperfusion of brain and myocardium -> cerebral anoxia and fatal arrhythmias

Question 21

How does haemorrhage affect the endothelium

Answer 21

Mounting oxygen debt and hypoperfusion -> endotheliopathy (systemic shedding of glycocalyx barrier) -> Endogenous heparinisation

Question 22

Massive transfusion

Answer 22

10+ PRBCs within 24 hours

Question 23

Advantages and disadvantages of defining ‘massive transfusion’

Answer 23

Adv - early identification of pts needing large volumes, mobilise resources early, improve outcomes
Disadvantages - antiquated, arbitrary, survival bias

Question 24

Critical administration threshold

Answer 24

3+ PRBCs during any 1 hour period in the first 24 hours/ first hour of resus

Question 25

Resuscitation intensity

Answer 25

All fluid and blood products within the first 30 mins of resus

Question 26

Disadvantage of the 4 classes of Haemorrhagic shock

Answer 26

Inaccurate in large databases of pts

Question 27

Aims of damage control resus

Answer 27

Early haemorrhage control Permissive hypotension Blood products for volume resus Target coagulopathy

Question 28

Principles of DCR

Answer 28

Direct pressure, tourniquets, pack wounds w haemostatic dressings Delay fluids until definitive haemostasis if possible Massive transfusion protocol Abtain functional lab measures of coagulation Avoid/correct hypothermia Minimise crystalloids Minimise imbalances in plasma, platelets and RBCs Reverse anticoagulant meds and address coagulopathy

Question 29

Major haemorrhage protocol

Answer 29

Multi modal package of care that rapidly provides standard iOS ed elements of medical treatment to patients with life threatening haemorrhage Treat empirically without waiting for results

Question 30

MHP activation criteria

Answer 30

Vary by institution Usually vital signs, lab data, and physician digression NICE: MOI, pt physiology, anatomical injury, pt response to initial resus

Question 31

Code red

Answer 31

Major haemorrhage protocol initiated prehospitally Included in hospital procedures - surgery, blood bank

Question 32

Code red criteria

Answer 32

Suspicion or evidence of active haemorrhage SBP <90 Failure of bp to respond to IV fluid bolus

Question 33

Disadvantages of previous definitions of massive blood loss such as ‘loss of 1§ blood volume in a 24 hour period’

Answer 33

Retrospective so prevents early recognition

Question 34

Who should activate code red

Answer 34

Most senior doctor at the scene

Question 35

RLH code red criteria

Answer 35

Haemodynamically unstable due to rapid and continuous blood loss Ongoing blood loss likely to need 4+ units RBCs HR 110+ and/or SBP <90

Question 36

Should o neg or o pos blood be used initially

Answer 36

Female o neg Male o pos

Question 37

What is in a code red pack

Answer 37

6u RBC 6u FFP 2 pools cryoprecipitate 1 pool platelets

Question 38

BASTE

Answer 38

Blood Acid base Surgical progress Temperature Electrolytes

Question 39

Shapes of normal, coagulopathicm and hyperfibrinolytiuc ROTEM

Answer 39

Normal - wine glass Coagulopathic - champagne flute (narrow) Hyperfibronlytic - rounded (puffer fish)

Question 40

What complication is more likely if more crystalloids are given in initial resus

Answer 40

MODS

Question 41

Why should crystalloids be avoided in trauma resus

Answer 41

Incr MODS risk Dilute clotting factors and platelets causing coagulopathy Cause acidosis Hypothermia

Question 42

How does saline affect acid base balance

Answer 42

Ph of normal saline is 5.0 causing acidosis Leads to coagulopathy as clotting enzymes denature

Question 43

Why are Plasmalyte and Hartman’s better than normal saline for trauma

Answer 43

Closer to ph 7

Question 44

PAMPER

Answer 44

Mortality at 30 days sig lower in plasma group than crytsalloid pts

Question 45

RCTs investigating use of whole blood

Answer 45

TROOP SWiFT

Question 46

Trimodal distribution of death

Answer 46

1st 3 hrs - bleeding First 5 days - head injury First wk - multiple organ failure

Question 47

Occult haemorrhage

Answer 47

Pt compensated until dying

Question 48

2 phases of Hypovolaemic shock

Answer 48

Tachycardia Reflex bradycardia (can be mistaken for improvement, periarrest sign)

Question 49

How does Haemorrhagic shock lead to endogenous heparinisation

Answer 49

O2 debt and hypoperfusion causes shedding of glycocalix barrier (endotheliopathy) Heparin is part of glycocalix barrier

Question 50

Max time for permissive hypotension

Answer 50

1 hour

Question 51

Code red

Answer 51

SBP <90 + suspected active haemorrhage protocol initiated

Question 52

ROTEM

Answer 52

ROTational ThromboElastoMetry Viscohaemoelastic assay