CAPT William C. Brunner, MC, USN
Senior Medical Officer, BSRF-2013
Assistant Professor, Department of Surgery

The speaker has no relevant financial relationships with commercial interests that pertain to the content of this presentation

• Review History of Trauma Resuscitation
• Discuss Coagulopathies in Trauma
• Discuss Integrated Damage Control
• Review Blood Component Preparations
• Discuss Individual Component Transfusion
Guidelines
• Discuss Massive Transfusion Protocols
• Discuss Future Research Areas

• World War I
– Little or no systematic resuscitation after injury
– Blood banking developed
• World War II
– Widespread use of blood and albumin
– Long, slow evacuation
– Significant organ failure – renal, pulmonary
– Late deaths from sepsis

• Korean War
– Forward Surgical Care
– Rapid Care
– Evacuation to Definitive Treatment
– Blood and albumin as in WWII
• Vietnam War
– Rapid evacuation
– Large-volume resuscitation with blood/crystalloid
– Da Nang Lung (ALI/ARDS)

• Civilian Experience
– Trauma Registries and Research
– Empiric high-volume crystalloid resuscitation
– Iatrogenic Coagulopathy after Trauma recognized
– Directed Component Therapy
• Requires Laboratory evidence
• Empiric therapy limited
– Massive Transfusion Protocols

• Military Experience – Iraq and Afghanistan
• Limited Component availability
• Recognition of crystalloid inflammatory response
• Whole blood transfusion
• Walking Blood Bank
– Simple technology
– Screened donor population readily available

• Recognized in patients with significant tissue injury and hypotension
• Distinct from iatrogenic coagulopathy after trauma
– Dilutional coagulopathy
• Present prior to resuscitation in rapidly evacuated severe trauma
• Mortality rate increased 4x
• Modulated through protein C activation

• Damage Control Surgery
– Rapid, limited, forward surgical care
• Control bleeding
• Control spillage
• Control contamination
• Restore perfusion
– Avoid unnecessary interventions
– Allow for resuscitation
– Rapid evacuation
• Hemostatic Resuscitation
– Limited volume
– Permissive hypotension
– Balanced transfusion
• High FFP:PRBC ratio
– Colloid vs. crystalloid
– Attenuate ATC
– Expand resource availability
• Walking blood bank
• Freeze-dried plasma

Component
Whole Blood
PRBCs
Leukocyte-reduced
PRBCs
Washed PRBCs
FFP
Cryoprecipitate
Platelets
Indication Storage Time Disadvantage
Volume deficit, O2 carrying capacity, massive transfusion
35 days (2°-6° C)
24 hrs fresh
Short shelf life
Immunomodulation
Cost
Volume deficit, O2 carrying capacity
Cardiac surgery, prevent CMV infection, reduce febrile reaction and alloimmunization
Prevention of allergic reactions
42 days
42 days
24 hrs
Coagulopathy, warfarin reversal
Von Willebrand disease,
Fibrinogen deficiency
Microvascular bleeding, thrombocytopenia
1 year
1 year
5-7 days
Plasma depletion
Risk of transfusionassociated sepsis

• Advantages
– Wider use of limited resources
• 1 donated unit – multiple products
– Longer storage life
– Lower costs in elective use
– More predictable availability
• Disadvantages
– Multiple donor antigen exposure
– Less efficacy in high volumes, Lab costs

• Fresh Frozen Plasma
– Prothrombin Time (PT) > 17 sec
– Clotting Factor Deficiency (<25% of normal)
– Massive Transfusion (1 unit/5units RBCs) or clinically bleeding
– Severe Traumatic Brain Injury
• Cryoprecipitate
– Fibrinogen < 100mg/dL
– Hemophilia A, von Willebrand disease
– Severe Traumatic Brain Injury

• Platelets
– Platelet count < 10,000/uL
– Platelet count 10,000 to 20,000 with bleeding
– Platelet count < 50,000 after severe trauma
– Bleeding Time > 15 mins
– Platelet concentrates (5.5 x 10 10 in 50ml)
– Platelet apheresis (3 x 10 11 in 300ml)

• Packed Red Blood Cells (PRBCs)
– Hemoglobin < 7g/dL
– Acute blood volume loss > 15%
– > 20% decrease in BP, or BP <100mm Hg due to blood loss
– Hemoglobin < 10g/dL with significant cardiac disease or symptoms (chest pain, dyspnea, fatigue, orthostatic hypotension)
– Hemoglobin < 11g/dL in patient at risk for MOF

• Defined as > 10 units PRBCs within 24 hrs
• 25-30% of trauma patients requiring massive transfusion will present with Acute Traumatic
Coagulopathy (ATC)
– Penetrating mechanism
– Positive FAST
– Arrival SBP < 90mm Hg, HR > 120 bpm
– Unstable pelvic fracture
– pH < 7.25, base deficit

• Advantages
– More closely replicate whole blood physiology with components
– Retain shelf-life advantage of components
– 25-30% reduction in PRBCs used
– Predictable workload
• Disadvantages
– Processing time limitations
– Limited applicability

4
5
2
3
6
1
Package
PRBCs (Units) FFP (Units) Platelets
(Units)
Other
6 6
6
6
6
6
6
6
6
6
6
1 apheresis
1 apheresis
Cryoprecipitate rFVIIa
6 1 apheresis Cryoprecipitate rFVIIa
Data from O’Keeffe T, Refaai M, Tchorz K, et al:
A massive transfusion protocol to decrease blood component use and costs, Arch Surg
143:686-691, 2008.

• Typically start with 2-6 units Type O blood
– Initial “emergency-release”
– Subsequent units type-specific, cross-matched
• FFP processing time
– ER prestaging thawed plasma, shelf-life 4-5 days
• Protocols can enhance effective use of staffing and resources

• Autotransfusion
– Limited applicability due to capture, possible contamination
• Blood salvage
– Intraoperative or postoperative
– Labor intensive, expensive, limited utility
• Autologous donation, Hemodilution not applicable to trauma setting

• Determine optimal therapeutic ratio of
PRBC:FFP
– PROPPR Study - 1:1:1 vs. 1:1:2 PRBC/PLT/FFP
• Further delineate ATC physiology and identify clinically useful modulators
• Delineate impact of high-ratio therapy on sub-
MT trauma population
• Blood component substitutes
• Crystalloid alternatives

• McIntyre RC Jr., Moore FA; Blood Transfusion
Therapy, Chapter 212, Current Surgical
Therapy, 10 th Edition, Philadelphia, PA, 2011.
• Adams CA Jr., Stephen A, Cioffi WG; Surgical
Critical Care, Chapter 23, Sabiston Textbook of
Surgery, 19 th Edition, Philadelphia, PA 2012.
• Chovanes J, Cannon JW, Nunez TC; The
Evolution of Damage Control Surgery, Surg Clin
N Am 92 (2012) 859-875.

• Cohen MJ. Towards Hemostatic Resuscitation:
The Changing Understanding of Acute
Traumatic Biology, Massive Bleeding, and
Damage-Control Resuscitation. Surg Clin N Am
92 (2012) 877-891.
• Committee on Trauma, American College of
Surgeons. ATLS: Advanced Trauma Life
Support Student Course Manual, 9 th Edition.
Chcago: American College of Surgeons; 2012.