Trauma - Transfusion in trauma Flashcards
(115 cards)
1
Q
What are the transfusion fluid options to consider in trauma?
A
- Fresh whole blood
- Packed red cells
- Fresh frozen plasma
- Cryoprecipitate
- Platelets
These options are essential for managing trauma patients effectively.
2
Q
What is a key component of resuscitation in trauma?
A
Oxygen delivery to tissues
Adequate oxygen delivery is critical for maintaining tissue viability during resuscitation.
3
Q
What happens when anaemia is present with Hb <70?
A
Causes increase in cardiac output
This compensatory mechanism helps maintain oxygen delivery.
4
Q
At what Hb level can oxygen delivery be maintained when breathing 100% oxygen?
A
Hb 30
This indicates a significant ability to sustain oxygenation despite severe anaemia.
5
Q
Which fluid types are contraindicated in trauma?
A
- Colloids
- Starch
- Albumin
These fluids have been shown to have negative effects in trauma patients, particularly regarding coagulopathy.
6
Q
What did the SAFE study reveal about albumin in trauma patients?
A
Increased mortality in patients that received albumin
This study highlighted the risks associated with using albumin in trauma settings.
7
Q
What benefits does fresh whole blood provide beyond oxygen carrying capacity?
A
- Oncotic pressure
- Coagulation factors
- Temperature homeostasis (if warmed)
Fresh whole blood offers comprehensive support for trauma patients, particularly when warmed.
8
Q
What is a limitation of fresh whole blood availability?
A
Limited outside of military environments
This is due to the challenge of having a large pool of healthy, screened donors.
9
Q
Transfusion/resuscitation with crystalloid and packed red cells only, leads to what?
A
Diluted clotting factors, contributing to coagulopathy
This highlights the importance of understanding the impact of transfusion strategies.
10
Q
What factors contribute to coagulopathy in trauma besides haemodilution?
A
- Direct injury factors
- Activated protein C
- Increased plasminogen activator and fibrinolysis
- Hypothermia
- Metabolic acidosis
These factors can complicate the resuscitation process and management of trauma patients.
11
Q
What is the survival benefit associated with platelet transfusion in trauma?
A
0.8 units of platelets given per unit of RBC
This ratio has been shown to improve outcomes in trauma patients.
12
Q
When should platelets be given as prophylaxis?
A
If platelet count <15000
This is crucial to prevent significant bleeding complications.
13
Q
What is the recommended platelet count threshold for pre-surgery transfusion?
A
<50000
Ensuring adequate platelet levels before surgery is critical to minimize bleeding risk.
14
Q
What is the typical need for fresh frozen plasma (FFP) in massively bleeding patients?
A
1 unit of FFP for every 1 unit of RBC
FFP is critical for providing necessary coagulation factors during massive hemorrhage.
15
Q
What is the volume of 1 unit of FFP?
A
250mL
This volume is important for calculating transfusion requirements.
16
Q
How does cryoprecipitate differ from FFP?
A
Contains fibrinogen, vWF/factor VIII complex, and factor XIII
Cryoprecipitate is more concentrated in certain coagulation factors but is typically used less frequently.
17
Q
What is the volume of 1 unit of cryoprecipitate?
A
10mL
This smaller volume is used for rapid increases in fibrinogen when necessary.
18
Q
What are the metabolic effects of transfusion?
A
Stored pRBC develop defects related to storage duration, significant when transfused rapidly.
Examples include storage-related decrease in ATP, degradation of 2,3-DPG affecting oxygen binding, and increased ammonia release due to red cell membrane disruption.
19
Q
What happens to ATP levels in stored red blood cells?
A
Decrease in ATP occurs over the storage duration, with clinical significance increasing when transfused quickly.
ATP levels drop in stored pRBC, impacting their functionality.
20
Q
How does 2,3-DPG degradation affect oxygen transport?
A
After 7-10 days, degradation of 2,3-DPG decreases oxygen binding affinity, dropping oxygen transporting ability by 2/3 after 7 days.
2,3-DPG is crucial for oxygen release from hemoglobin.
21
Q
What causes increased ammonia release during blood storage?
A
Release of intracellular protein occurs after disruption of red cell membrane during storage.
This process contributes to metabolic changes in stored blood.
22
Q
What is hyperkalaemia in the context of blood transfusion?
A
Serum K+ rises in stored blood due to decreased efficiency of the Na/K pump, with concentrations potentially exceeding 40mmol/L.
Transient hyperkalaemia may occur with transfusion but often does not require correction.
23
Q
What coagulation abnormalities can occur due to transfusion?
A
Haemodilution leads to proportional loss of coagulation factors, particularly relevant in excessive, non-balanced RBC transfusion.
Monitoring coagulation function is crucial, especially in trauma cases.
24
Q
What is the effect of thawed FFP on coagulation factors?
A
Thawed FFP contains all coagulation factors, but Factor V and VIII have short half-lives and decrease quickly to subnormal levels at 7-14 days.
This makes timely administration important after thawing.
25
What is the significance of monitoring coagulation function in trauma?
Monitoring is important to assess coagulation status, particularly using TEG (thromboelastography).
## Footnote
TEG provides real-time assessment of coagulation and can guide transfusion strategies.
26
Fill in the blank: The half-life of platelets is ______.
short
## Footnote
Platelets are not present in packed red cells, necessitating careful management of platelet levels.
27
What are the main risks of blood transfusion?
Infectious, Haemolytic transfusion reaction, Immunological reactions
## Footnote
These categories encompass various complications that can arise from blood transfusions.
28
What types of infections can be transmitted through blood transfusions?
Hepatitis A, B, C and D, HIV, CMV, Atypical mononucleosis, Malaria, Brucellosis, Yersinia, Syphilis
## Footnote
These infections are examples of blood-borne pathogens that can be transmitted during transfusions.
29
What causes haemolytic transfusion reactions?
Incompatibility – ABO, rhesus and other surface antigens, Very cold blood, overheated blood, pressurised blood
## Footnote
These factors can lead to adverse reactions when incompatible blood is transfused.
30
What is a major incompatibility reaction?
Usually caused by administrative errors and giving the ‘wrong’ blood
## Footnote
This serious reaction can occur during blood transfusions if the blood type is not properly matched.
31
What is graft vs host disease in the context of transfusion?
A condition that can occur as a result of blood transfusion, where donor immune cells attack the recipient's tissues
## Footnote
This is a rare but serious immunological complication of transfusions.
32
What is transfusion-related acute lung injury?
A serious immunological reaction that can occur after blood transfusion
## Footnote
This condition can cause severe respiratory distress following transfusion.
33
How does immunomodulation affect patients receiving blood transfusions?
Increases ratio of suppressor T cells, rendering patient more susceptible to infection
## Footnote
This effect suggests that transfusions can negatively impact the immune system.
34
What should be the approach to blood transfusion in most patients?
Use blood in a rational and restrictive way
## Footnote
This approach aims to minimize risks associated with transfusions while still addressing patient needs.
35
What is the current best practice for blood transfusion in trauma cases?
Prioritising balanced resuscitation and haemostasis to secure clotting and oxygenation
## Footnote
In trauma situations, immediate transfusion is often necessary, and careful management is crucial.
36
What is the initial management approach for haemorrhage?
Aggressively pursue diagnosis and treatment of haemorrhage
## Footnote
This includes rapid identification of the source of bleeding and initiation of appropriate interventions.
37
What should be done to fluids during treatment of haemorrhage?
Titrate fluids to maintain permissive hypotension until haemostasis secure
## Footnote
Permissive hypotension allows for lower blood pressure to minimize further bleeding.
38
Which indicators should be monitored as part of haemorrhage management?
pH and lactate
## Footnote
These indicators help assess tissue perfusion.
39
What is the goal for Hb levels during haemorrhage control?
Aim for Hb 70-90
## Footnote
Higher Hb levels may be required in patients with comorbidities.
40
What is the recommended approach to ventilation in haemorrhage management?
Control ventilation to achieve saturation of 99-100 and normal end-tidal CO2
## Footnote
Proper ventilation helps optimize oxygen delivery to tissues.
41
What should be done if a massive transfusion is likely?
Attempt from outset to maintain intravascular composition
## Footnote
This helps to stabilize the patient’s blood volume and composition.
42
What is the transfusion threshold when Hb is below 70?
Generally if <70 then transfuse
## Footnote
Higher thresholds may apply in cases of ongoing bleeding or significant comorbidities.
43
What is the recommended transfusion ratio of pRBC:FFP:platelets?
1:1:1
## Footnote
This ratio is supported by recent research for optimal outcomes.
44
What should be avoided to prevent complications during haemorrhage management?
Avoid hypothermia and acidosis
## Footnote
These conditions can worsen patient outcomes during treatment.
45
What is the general transfusion policy in ICU?
Restrictive transfusion policy
## Footnote
A restrictive approach minimizes unnecessary transfusions while addressing critical needs.
46
What is controversial about the RBC to FFP ratio in transfusions?
The initial 2 units of pRBC followed by 1:1:1
## Footnote
This approach may vary based on clinical judgement and specific patient scenarios.
47
What is the typical ratio of apheresis platelets used in transfusions?
5:5:1 or 6:6:1
## Footnote
This ratio accounts for the units contained in apheresis platelets.
48
What is the aim for monitoring pH and lactate in patients?
To assess tissue perfusion
49
What is a critical component of treatment for deficiencies and complications during haemorrhage?
Treat deficiencies and complications as they arise
## Footnote
Timely treatment can prevent further deterioration of the patient's condition.
50
What is the purpose of developing capacity for cell salvage?
Reduce need for transfusion
## Footnote
Cell salvage allows for the collection and reinfusion of a patient's own blood.
51
What is Recombinant Activated Factor VII used for?
Has evidence it reduces transfusion requirement
With better understanding and assessment of clotting process, not as widely used now
52
What is the main use of Tranexamic Acid?
It is used when there is evidence of hyperfibrinolysis – as measured on TEG
## Footnote
The CRASH-2 trial showed a reduction in mortality, but there were methodological issues. (less than ½ of patients required red cell transfusion, same use of blood in both arms, mortality rate did not correlate with other studies
53
What were the methodological issues identified in the CRASH-2 trial?
Less than ½ of patients required red cell transfusion, same use of blood in both arms, mortality rate did not correlate with other studies
## Footnote
More information can be found at https://www.wikijournalclub.org/wiki/CRASH-2.
54
What recent evidence suggests about severely injured patients and fibrinolysis?
Majority may have fibrinolysis shutdown, therefore TXA may have no effect
## Footnote
This indicates the need for careful assessment before using TXA.
55
What is the function of Desmopressin?
It potentiates the function of platelets
## Footnote
It is indicated only for functional platelet disorders or patients on antiplatelet medication.
56
True or False: Recombinant Activated Factor VII is widely used now.
False
## Footnote
Its usage has decreased due to better understanding of the clotting process.
57
Fill in the blank: Tranexamic Acid is primarily used in cases of _______.
hyperfibrinolysis
58
What metabolic defect develops in stored pRBC as storage duration increases?
Defects in stored pRBC develop proportionate to duration of storage, affecting clinical significance when transfused rapidly
## Footnote
Examples include decreased ATP and degradation of 2,3-DPG.
59
How does the storage time of red blood cells affect oxygen transport?
After 7 days, the oxygen transporting ability drops by 2/3 due to degradation of 2,3-DPG
## Footnote
This affects the binding affinity of oxygen.
60
What occurs with increased ammonia release during blood storage?
Increased ammonia release occurs with the release of intracellular protein after disruption of red cell membrane during storage
## Footnote
This is a metabolic effect of blood storage.
61
What happens to serum potassium levels in stored blood?
Serum K+ rises as the efficiency of the Na/K pump decreases
## Footnote
Transfused blood may have concentrations >40mmol/L.
62
Does transient hyperkalaemia require correction after transfusion?
Often does not require correction
## Footnote
This is due to the transient nature of hyperkalaemia occurring with transfusion.
63
What causes coagulation abnormalities during transfusion?
Haemodilution and proportional loss of coagulation factors
## Footnote
More relevant for excessive, non-balanced RBC transfusion.
64
What does thawed FFP contain?
All coagulation factors
## Footnote
However, Factor V and VIII have short half-lives.
65
What happens to Factor V and VIII levels after thawing FFP?
They decrease quickly to subnormal levels at 7-14 days
## Footnote
These factors are critical for coagulation.
66
Do packed red cells contain platelets?
No, packed red cells do not contain platelets
## Footnote
The half-life of platelets is also short.
67
Why is monitoring coagulation function important in trauma?
It is important particularly with TEG – thromboelastography
## Footnote
This monitoring helps assess coagulation status.
68
Give examples of infections that can be transmitted via blood transfusion.
Blood borne infections: Hepatitis A, B, C and D, HIV, Cytomegalovirus, Atypical mononucleosis, malaria, brucelosis, yersinia, syphilis
## Footnote
A common virus that can cause disease in people with weakened immune systems.
69
What are haemolytic transfusion reactions?
Reactions that occur when transfused blood cells are destroyed by the recipient's immune system
## Footnote
Can be caused by blood type incompatibility.
70
What types of incompatibility can cause transfusion reactions?
ABO, rhesus and other surface antigens
## Footnote
Incompatibility can lead to serious and life-threatening reactions.
71
What are some conditions that can cause transfusion reactions?
Very cold blood, overheated blood, pressurised blood
## Footnote
These conditions can lead to adverse effects during a blood transfusion.
72
What is an immediate generalised reaction in the context of blood transfusion?
A rapid and widespread response to a transfusion that can be life-threatening
## Footnote
Often requires immediate medical attention.
73
What is a major incompatibility reaction typically caused by?
Administrative errors and giving the ‘wrong’ blood
## Footnote
This can result in severe hemolytic reactions.
74
What is graft vs host disease?
A condition that occurs when transfused immune cells attack the recipient's tissues
## Footnote
Can be fatal and is a concern in immunocompromised patients.
75
What is transfusion-related acute lung injury?
A serious complication of blood transfusion leading to respiratory distress
## Footnote
Often associated with antibodies in the donor blood reacting with recipient immune cells.
76
What is immunomodulation in the context of blood transfusions?
A process that increases the ratio of suppressor T cells, rendering the patient more susceptible to infection
## Footnote
This can complicate patient recovery.
77
What should be considered when using blood transfusions?
Blood transfusion has effects and side effects – some of which are ‘bad’. We should use blood in a rational and restrictive way in most patients
## Footnote
This approach minimizes risks associated with transfusions.
78
What is the current best practice for blood transfusions in trauma?
Prioritising balanced resuscitation and haemostasis secures clotting and oxygenation
## Footnote
There are currently no good alternatives to blood transfusion in trauma cases.
79
What is the primary goal in the initial management of hemorrhage?
Aggressively pursue diagnosis and treatment of haemorrhage
## Footnote
This involves identifying the source of bleeding and addressing it promptly.
80
What should be monitored as indicators of tissue perfusion?
pH and lactate
## Footnote
Abnormal levels may indicate inadequate tissue perfusion.
81
What is the target Hb level during hemorrhage control?
70-90
## Footnote
Higher Hb levels may be required in patients with comorbidities.
82
What is the recommended approach to fluid management until hemostasis is secure?
Titrate fluids to maintain permissive hypotension
## Footnote
This strategy helps minimize further bleeding.
83
What should be the aim for oxygen saturation and end-tidal CO2?
Saturation of 99-100 and normal end-tidal CO2
## Footnote
Proper ventilation is crucial for tissue oxygenation.
84
What is the recommended transfusion threshold in the absence of ongoing bleeding?
Generally if <70 then transfuse
## Footnote
Higher thresholds may be necessary for ongoing bleeding or significant comorbidities.
85
What should be done to reduce the need for transfusion?
Maintain intravascular composition
## Footnote
This may involve early interventions and management strategies.
86
What is the recommended ratio for transfusion of pRBC:FFP:platelets according to research?
1:1:1
## Footnote
This approach has shown benefits in trauma care.
87
What should be done if massive transfusion is likely?
Attempt from outset to maintain intravascular composition
## Footnote
Early management can improve outcomes.
88
What is the general approach to transfusion policy in ICU?
Restrictive transfusion policy
## Footnote
This policy aims to minimize unnecessary transfusions.
89
What is the controversy regarding the ratio of RBC to FFP in transfusions?
Initial 2 units of pRBC followed by 1:1:1
## Footnote
The optimal ratio is still debated in clinical practice.
90
What should be done to treat deficiencies and complications as they arise?
Treat cause – urgent surgery to stop bleeding, avoid hypothermia and acidosis
## Footnote
Immediate intervention is crucial for patient stabilization.
91
What is the typical composition of apheresis platelets used in transfusions?
Usually contains 5 or 6 units of platelets
## Footnote
This affects the transfusion ratios when using apheresis platelets.
92
List three adjuncts to transfusion
TXA
Recombinant activated factor VII
Desmopressin
93
List 7 tests for coaguation monitoring
Traditional assays - coag screen
Fibrinogen degredation products
INR
PTT
D-dimer
All are cost effective, but all are time consuming, and not appropriate in hypothermic patient
Viscoelastic haemostatic assays (VHAS)
Thromboelastography (TEG)
94
What is Thromboelastography (TEG) ?
What?
Gives a visual representation of clotting function as a whole, and function of all components can be ascertained
How ?
Collected blood placed in a small cup
Inside cup is suspended pin connected to detector system, the cup and pin are oscillated relative to each other
As fibrin string forms between the cup and pin, the transmitted rotation from cup to pin is measured
Trace then generated
95
96
What is the definition of massive transfusion?
Replacement of 100% (total) blood volume in <24h
## Footnote
This definition highlights the urgency and extent of blood volume replacement in critical situations.
97
What is the administration threshold for blood volume in massive transfusion?
Administration of 50% of blood volume in 4 hours
## Footnote
This threshold indicates a rapid response requirement in massive transfusion protocols.
98
What is a disadvantage of the current definition of massive transfusion?
It is retrospective and limited clinical value
## Footnote
This limitation suggests that the definition may not effectively guide real-time clinical decisions.
99
What would be more helpful than the current definition of massive transfusion?
Identifying which patient will develop major haemorrhage requiring MTP
## Footnote
This approach focuses on prevention and early intervention in patients at risk.
100
What is the primary clinical decision regarding MTP?
An MTP should be activated when there is massive haemorrhage or ongoing active bleeding in patients with signs of Shock
## Footnote
MTP stands for Massive Transfusion Protocol.
101
What is the ABC score used for?
Predicts need for massive transfusion when score <2
## Footnote
The ABC score assesses various clinical factors to determine the necessity of blood transfusions.
102
What factors are included in the ABC score?
* Penetrating mechanism
* Evidence of bleeding (FAST)
* Signs of Shock (BP↓, HR↑)
## Footnote
FAST stands for Focused Assessment with Sonography for Trauma.
103
What is the scoring for a penetrating mechanism in the ABC tool?
1 point for a penetrating mechanism
## Footnote
This indicates the type of injury that may lead to significant blood loss.
104
What systolic BP value contributes to the ABC score?
Systolic BP <90mmHg (1 point)
## Footnote
This indicates a critical level of blood pressure that suggests shock.
105
What heart rate contributes to the ABC score?
HR >120bpm (1 point)
## Footnote
An elevated heart rate can indicate shock and the need for urgent intervention.
106
What does a positive FAST scan contribute to the ABC score?
1 point for a positive FAST scan
## Footnote
A positive FAST scan indicates the presence of fluid, likely blood, in the abdominal cavity.
107
What does a score of 2 or more in the ABC tool indicate?
Predicts likelihood of needing MTP with 75% sensitivity, 86% specificity
## Footnote
Sensitivity and specificity are statistical measures of the performance of a diagnostic test.
108
What is the first goal of massive transfusion protocol?
Recognise and assess blood loss
## Footnote
This involves evaluating the extent of hemorrhage to determine the necessary interventions.
109
What is the aim of restoring intravascular volume in massive transfusion protocol?
Restoration of intravascular volume and haemoglobin
## Footnote
This is critical to maintaining adequate tissue perfusion and oxygen delivery.
110
What does definitive control of bleeding involve?
Definitive control of bleeding via surgical or other means (radiological)
## Footnote
This may include procedures to directly address the source of hemorrhage.
111
What is meant by 'correction of other parameters' in the context of massive transfusion protocol?
Correction of coagulopathy, acidosis, electrolyte imbalance, hypothermia
112
What should be monitored according to the massive transfusion protocol?
Monitor - see protocol
## Footnote
Monitoring includes tracking vital signs, laboratory values, and overall patient condition.
113
What is one of the early goals in the optimization phase of massive transfusion protocol?
Early arrest of bleeding
## Footnote
Quick intervention is crucial to prevent further blood loss.
114
What does the term 'lethal triad' refer to in massive transfusion protocol?
Prevent lethal triad
## Footnote
The lethal triad consists of coagulopathy, hypothermia, and acidosis, which can worsen patient outcomes.
115
What is the importance of normothermia in massive transfusion protocol?
Maintaining normal body temperature is essential for optimal coagulation and metabolic function.
