|Initial Trauma Assessment and Management
|Thoracic Trauma Assessment and Management
|Flail Chest Rib fractures
|Traumatic Head/Brain Injury
|Traumatic Cardiac Arrest
"Bleeders come first" Bleeding may be hidden and may be from more than one site
- Haemorrhage when unmanaged kills quickly.
- IV fluids do not carry oxygen and dilute clotting factors so once you have given 1 L of crystalloid you should be giving blood [O Negative if needed].
Causes of Bleeding
- Vessel wall
- Collagen diseases
- Hereditary haemorrhagic telangiectasia
- Senile purpura
- Steroid usage
- Trauma e.g. marching gives lower limb purpura
- Severe infections
- Clotting system
- Warfarin usage
- Heparin usage
- DIC - consumption of clotting factors
- Haemophilia A and B
- Von Willebrand's
- Platelets - low numbers or dysfunction
- Idiopathic thrombocytopenic purpura
- Von Willebrand's disease
- Aspirin usage (irreversible COX inhibition)
- Thrombocytopenia due to marrow failure or malignancy
Hypovolaemic shock severity
Investigating for Medical Cause
- Check FBC for platelets: thrombocytopenia
- Check Prothrombin time: Lack of Factor II, V, VII or X. Give IV Vitmain K or Octaplex/Beriplex
- Check APTT: Decrease in all factors: Consider FFP which has all clotting factors
- Fibrinogen level: Low : Give Cryoprecipitate
- Thrombin time (TT): abnormal fibrinogen
- Fibrinogen degradation products: DIC
Managing blood loss
- When considering if a trauma patient needs some sort of IV fluid replacement, there are two competing priorities.
- (1) Maintaining circulation. This requires a reasonable blood pressure and volume to be within the circulation to ensure perfusion of tissues and organs. If this were your only priority,
you would give lots of fluids
- (2) Preserve activity of the coagulation system. This can be impaired either by dilution of
clotting factors (from eg. crystalloid or colloid fluids, or bags of red blood cells), by
consumption of clotting factors (from the body attempting to clot, but bleeding continuing
unabated) or from the patient becoming cold (which can be exacerbated by giving unwarmed
fluids or blood). If this were your only priority, you would not give any fluids at all.
- There is good evidence that giving large volumes of IV fluids to bleeding trauma patients will increase their mortality therefore, blood products are usually transfused early (once you are approaching 1 litre of crystalloid fluids, you should definitely be giving some blood).
- The first type of blood product required are red blood cells - the oxygen-carrying component of blood. If you anticipate giving a reasonable amount of blood either because the patient is displaying signs of being unstable, or they have a bleeding source that you can immediately control (ie. Anything internal), then you should activate the major haemorrhage
protocol. This is normally done by phoning the switchboard.
Major haemorrhage is variously defined as:
- Loss of more than one blood volume within 24 hours (around 70 mL/kg, >5 litres in a 70 kg adult)
- 50% of total blood volume lost in less than 3 hours
- Bleeding in excess of 150 mL/minute.
- A pragmatic clinically-based definition is bleeding which leads to a SBP < 90 mm Hg or a HR > 110 beats per minute.
- If Hb falling : Transfuse RBCs
- If PT>1.5 then Fresh frozen plasma FFP 15-20 ml/kg
- If Fibrinogen < 1.5 g/L then Cryoprecipitate (2 pools)
- If platelets < 75 then Platelets 1 ATD
- O negative (after samples are taken for blood grouping and cross matching) there will usually be 2 or 4 units immediately available in the Emergency Department
fridge or the laboratory. Females, less than 50 years of age should receive RhD negative red cells to avoid sensitisation.
- Type specific: prepared by the laboratory and will take about 15 minutes to prepare (from their receipt of the patient's blood sample). This is a compatible ABO and rhesus group for the patient but has not been tested against the patient's blood so there is a risk of more minor incompatibilities.
- Cross-matched: prepared by the laboratory. It usually takes about 30-40 minutes to be prepared, and the patient's blood has been tested with the donors so that you are very unlikely to
experience any incompatibilities
- Bags of red cells contain red blood cells, some water and
electrolytes. They contain no clotting factors, fibrinogen or platelets. So after a few bags of red cells, there is a risk that you will dilute the patients clotting factors. These, therefore, will also start to need replaced which is initially with fresh frozen plasma (FFP).
- There is no hard rule as to when to initiate this, but generally speaking, if a patient has had 4 units of red cells then they will need some FFP too. If you need to continue transfusing red blood cells, then they may need some more specialized blood products these are platelets and cryoprecipitate.
- Cryoprecipitate is a bit like FFP but contains much higher levels of fibrinogen. Remember to keep in
touch with the haematologist and laboratory and send regular full blood count and coagulation
samples to them.
- Tranexamic acid: This is an anti-fibrinolytic drug, which means it inhibits the breakdown of clots. It
is very cheap with an excellent side-effect profile. There is evidence that it reduces mortality in
trauma patients who are bleeding, so you should give it to anyone who you are transfusing. The dose is 1 gram over 10 minutes, followed by 1 gram over 8 hours.
- NB: IV fluids and blood products should be warmed before being given to a patient this is particularly true of blood products as many of them will have come from the fridge and be very cold.
Packed red cells