A 24-year-old male was involved in a motor vehicle accident. On arrival to the trauma bay, he is noted to have an open tibia-fibula fracture with significant blood loss. His systolic blood pressure (BP) is 65 mm Hg.
Appropriate resuscitation includes:
Correct Answer: C
Studies assessing transfusion ratios found that patients who were transfused in a 1:1:1 ratio were more likely to have adequate hemostasis and have fewer exsanguination deaths at 24 hours, and in some cases lower mortality at 30 days. Given he has “significant” blood loss and is hypotensive, a fluid bolus would be less than adequate. Cryoprecipitate should be administered when a patient has hypofibrinogenemia.
References:
A 45-year-old male with open bilateral femur fractures is brought in with a systolic BP of 58 mm Hg. He has delayed capillary refill, and heart rate (HR) is 168. Based on his clinical presentation, he has likely lost:
Correct Answer: D
Class 3 hemorrhage is distinguished from less severe forms of hemorrhage by the development of hypotension and is associated with >30% of blood volume loss.
Reference:
A 23-year-old male is brought to the emergency department by emergency medical services (EMS) with a penetrating abdominal wound. Initial vital signs are HR 127 and BP 84/36. One unit of uncrossmatched blood is given as he is sent emergently to the operating room (OR) for exploratory laparotomy. During the procedure, 2 L of blood is evacuated immediately and ongoing bleeding is appreciated.
What is the best initial fluid resuscitation strategy?
Correct Answer: A
This patient meets the criteria for hemorrhagic shock, the second most frequent cause of death in trauma patients and a leading cause of early inhospital trauma mortality. Resuscitation of patients with massive hemorrhage has moved from reactive strategies based on laboratory values to proactive, standardized massive transfusion protocols (MTPs). A labbased approach to transfusion in hemorrhage can lead to a delay in the recognition and treatment of a rapidly developing anemia and coagulopathy. Additionally, excessive crystalloid or nonblood colloid should be avoided to limit hemodilution and coagulopathy exacerbation.
The Prospective, Observational, Multicenter, Major Trauma Transfusion (PROMMTT) study found that patients transfused with ratios of plasma:PRBCs or platelets:PRBCs of 1:1 or higher were less likely to die in the first 24 hours than those with ratios less than 1:2. This is especially notable, as most hemorrhagic deaths occur in the first 6 hours of admission.
A 44-year-old, 70 kg female with a history of insulin-dependent diabetes, nonobstructive coronary artery disease (CAD), heart failure with preserved ejection fraction, and chronic kidney disease with a baseline Cr 1.6 is admitted to the intensive care unit (ICU) intubated after a laparoscopic appendectomy complicated by rupture of the appendix during resection. Blood loss was minimal, per surgical hand off. First set of ICU vital signs:
Preliminary set of labs are remarkable for:
After a 1 L crystalloid bolus and initiation of a norepinephrine drip at 4 µg/min, BP is now 96/54.
What is the best strategy for ongoing resuscitation?
Anemia is a common condition in the ICU, with studies showing that two-thirds of ICU patients have a Hgb <12 on the day of admission, and 97% of patients become anemic after a week in the ICU. The etiology is often multifactorial and is associated with worse outcomes.
The Transfusion Requirements in Critical Care (TRICC) trial examined differences in mortality between euvolemic, critically ill patients randomized to a liberal transfusion strategy with goal Hgb >10 g/dL or a restrictive transfusion strategy with goal Hgb >7 g/dL. A restrictive transfusion strategy was associated with significantly lower in-hospital mortality. The benefit was most prominent among the younger (age <55 years) and less critically ill (APACHE score <20) subset. Other studies have demonstrated no difference in mortality, ischemic events, or life support requirements in patients with septic shock transfused to goal Hgb >7 or >9.
In this patient with septic shock, the Surviving Sepsis guidelines recommend initial resuscitation of 30 mL/kg, or 2.1 L in this 70 kg patient, and she would benefit most from a second 1 L crystalloid bolus. Platelets should not be used for expansion of the circulatory volume in a patient without signs of active bleeding and platelets >50 000/mm3.
An 83-year-old male with a history of chronic kidney disease, hypertension, and insulin-dependent diabetes is admitted to the floor with a small bowel obstruction. After 2 days of conservative therapy, HR is now 118 with MAP <65 despite repeated crystalloid boluses, and he has peritonitic signs on abdominal examination. The plan is to go to the OR for an exploratory laparotomy and small bowel resection.
What is the goal platelet count before surgery?
Thrombocytopenia is common in the critically ill population, and it serves as an independent predictor of mortality. Critical illness–associated thrombocytopenia is multifactorial; it often results from a combination of bone marrow suppression, consumption of coagulation factors, and increased turnover. Few randomized trials of prophylactic platelet transfusion thresholds mean to prevent, rather than treat, bleeding in critically ill patients, and recommendations are based largely on expert opinion and institution-specific guidelines. Most of the current guidelines have been extrapolated from oncology patients with chemotherapyassociated thrombocytopenia. Current consensus guidelines recommend prophylactic platelet transfusion for counts <10 000/mm3 in the absence of bleeding or for counts <20 000/mm3 for patients at high-risk of bleeding. Platelet counts >50 000/mm3 are recommended for active bleeding, surgery, or other invasive procedures. Surgery at critical sites, such as ocular surgery and neurosurgery, often requires counts >100 000/mm3 .
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