Sunrise Hospital and Medical Center
Sunrise Children’s Hospital
Sunrise Trauma Service
Policy/Procedure Statement
TSUxxxx
Policy: Trauma Exsanguination Protocol
Effective Date: draft
Supercedes Date: new
I.
Purpose:
The Exsanguination Policy is designed to:
A. Ensure timely and appropriate treatment of hemorrhagic shock and
accompanying coagulopathy.
B. Maximize the use of blood and blood component resources.
C. Favorably affect patient outcome.
II.
Policy:
Trauma patients who are in hypovolemic shock, have volume-dependent
hypotension, or are likely to require 10 units of red cells, should have the
Exsanguination Protocol activated by the Trauma Surgeon (TS), or the Trauma
Anesthesiologist (TA).
This policy is designed to outline the responsibilities required to ensure that a patient
who requires blood product replacement is managed effectively in the event of
multiple blood products and the collaborative efforts of the Trauma Team, O.R.,
Trauma Intensive Care Unit, Blood Bank and the Pharmacy departments.
ii. Indications for invoking the Trauma Exsanguination Protocol.
a. Clinically massive hemorrhage in a hard to control body area
b. Belief that 100%% of a patient’s blood volume will be replaced within 24
hours
c. Rapid use of 5 units of blood without signs of hemorrhage control
d. At discretion of trauma surgeon and/or anesthesiologist
iii.
a. Communication to Blood Bank personnel is critical for the necessary steps
in preparing any blood product to leave the Blood Bank.
b. A call and an emergency blood release form stamped for Exsanguination
Protocol must be initiated by the Trauma RN scribe*. Keep Blood Bank
informed of patient location when possible.
c. A designated Contact Person in Blood Bank will organize the issuing of
products and can be reached at extension 1-8058. No products can be
picked up without a patient identification sticker.
III.
Procedure:
STEP ONE:
a. The TS/TA have determined to initiate the Exsanguination Protocol:
b. The TS/TA will order transfusion boxes in the following order: Box A-1, Box A2, Box-B
c. A decision by TS or TA regarding VIIa will be made at the time Box B is
ordered
d. Following Box B, TS or TA can request further boxes in any order, or
individual blood products.
e. A call to Blood Bank is made by the DESIGNAGTED TRAUMA NURSE FOR
SHIFT TO BE THE EXSANGUINATION RN (EP RN)-- for “Box A-1” of the
Exsanguination Protocol. All of the following products must be included to be
considered a complete order.
5 Units of PRBC
4 Units of FFP-or 2 Double Units
1 Single-donor platelet
c. The Blood Bank personnel is responsible for ensuring all products are
immediately available for Box 1; and the process for ensuring Box 2 products
are being assembled for dispensing.
STEP TWO:
a. It is determined by either the TS or TA that Box A-2 is needed: Box A-2
contains the following:
5 Units PRBC
4 Units FFP-or 2 Double
Units
1-Single donor Platelet
b. The Blood Bank personnel assigned to this process is responsible for ensuring
that any MISSING or Incomplete Box products are readied immediately
and the EP RN is notified when ready to pick-up. The designated
EP RN will ensure the missing products are delivered to the
location of the patient
STEP THREE:
a. It is determined by either the TS or TA that Box B is required: The designated
Trauma EP RN to be contacted by Vocera to deliver to the appropriate
location.
5 Units PRBC
4 Units FFP
1 –Single Donor Platelet pack
10 pack cryoprecipitate
order form for Factor VIIa to be
filled out by designated Trauma
EP RN and delivered to
pharmacy with the patients
name and weight.
STEP FOUR:
IV. EP RN: Responsibilities
a. EP RN is identified on the Trauma Board each shift
b. Must wear a Vocera badge and must logged in as the “EP RN”
c. The role must take precedence over ALL other duties when the EP protocol is
initiated
d. At any time during the exsanguination protocol, if the TS or TA calls to terminate
the protocol, the EP RN must notify Blood Bank immediately.
V. Trauma Surgeon and Trauma Anesthesia Responsibilities
a. TA first call must wear Vocera and log in as “Trauma Anesthesia”
b. TS first call must also have Vocera on during his/her call.
VI. Activated Factor VII (VIIa) use-MUST USE pre-printed FACTOR VIIa ORDER FORM
Prior to use of VIIa (except for hemophilic replacement) the following will be
controlled as far as the clinical situation permits:
a. Control macrovascular bleeding by surgery or angioembolization
b. Blood-component based strategy with PRBCs, FFP, platelets, and
cryoprecipitate as described in this protocol.
c. Attempt to maintain normal pH (greater than7.2), Temperature (greater than
35 degrees C) and Ionized Calcium (1.16mmol/L to 1.32mmol/L)
d. Minimize crystalloid use.
e. Avoid synthetic colloids (Dextrans, starches).
f. Standard blood component therapy includes:
1. Hemoglobin range approximately 8 to 10 if possible.
2. FFP to maintain INR less than or equal to1.5
3. Platelets to maintain greater than 50,000 (preferably
greater than100,000)
4. Cryoprecipitate to maintain Fibrinogen greater than100
mg/dL
Contraindications to FVIIa
FVIIa is not used for prophylaxis (exception: elective surgery in appropriate
hemophiliacs as per hematology recommendations)
Coagulopthic bleeding in an unsalvageable patient
Coagulopthic bleeding in a patient with MI, PE, CVA, DVT in last 6 months
(relative contraindication)
Dosage of Factor VIIa
Dosage – Recommended Dose-100 micrograms per kilogram. Lesser doses (10
to 20 micrograms/Kg, e.g. 1.2 mg) will normalize INR immediately in warfarin
associated coagulopathy.
VII. Pediatric patient population:
Dosage- Recommended Dose-100micrograms per kilogram unless otherwise
indicated.
References:
Holcomb, JB, Hess, JR: Early Massive Trauma Transfusion: State of the Art. Journal of
Trauma. 2006; 60:S1-S2
Walter Reed Army Institute of Research; US Army Institute of Surgical Research, Walter
Reed Army Medical Center; paper presentation, 2007 AAST; “Increased mortality
associated with the early coagulopathy of trauma in combat casualties
Tulane University, Louisiana State University; paper presentation; 2007 AAST ; “Review
of current blood transfusion strategies in a mature level I trauma center. “
Vanderbilt University Medical Center, HL Corwin MD Dartmouth-Hitchcock Medical
Center; paper presentation; 2007 AAST; “Improved survival of critically ill trauma patients
treated with recombinant human erythropoietin”
Committee Approval:
Trauma Committee:
Date:
Blood Usage Committee:
Date: 10/14/2008
Surgery:
Date:
MEC
Date:
BOT:
Date: