SGEM386: Blood on Blood – Massive Transfusion Protocols in Older Trauma Patients

Date: December 16th, 2022 Reference: Hohle et al. Massive Blood Transfusion Following Older Adult Trauma: the Effect of Blood Ratios on Mortality. AEM December 2022 Guest Skeptic: Dr. Kirsty Challen is a Consultant in Emergency Medicine at Lancashire Teaching Hospitals. She is also the wonderful educator that creates the Paper in a Pic infographics summarizing each SGEM episode. Case: A 71-year-old man is brought to your emergency department (ED) by emergency medical serviced (EMS) having fallen two steps at home. EMS have already splinted an obvious mid-shaft femoral fracture, but he continues to be tachycardic and hypotensive. After a bedside ultrasound shows fluid in the right hemithorax, you insert an intercostal drain which immediately fills with one litre of blood. Noting with some relief that at least he isn’t anticoagulated, you activate the hospital massive transfusion protocol. The transfusion tech calls to remind you that your protocol is currently under review, and asks if would you like the 1:1 or the 1:3 version of fresh-frozen plasma (FFP) to packed red blood cells (pRBC)? Background: Major trauma in older patients is increasing in frequency (1), with the median age of major trauma patients in the UK from 2012-2017 being 63.6 years (2). Falling is the most common cause of traumatic injury resulting in older adults presenting to the ED [4]. Approximately 20% of falls result in injuries, and falls are the leading cause of traumatic mortality in this age group [5,6,7]. Over the last few years there has been increasing concern that the practice of transfusing only PRBC might worsen traumatic coagulopathy. Although a number of trials have attempted to find optimal ratios for transfusion components and the Eastern Association for the Surgery of Trauma practice guidelines suggest a “high” ratio, little of the literature has addressed how this might be applied in an older population. We looked at the PROPPR trial on SGEM#109 when it came out in 2015 and concluded then that a 1:1:1 transfusion strategy was a reasonable approach to massive transfusion and that it seemed to achieve more hemostasis and less death from exsanguination at 24 hours. We’ve also looked at trauma in older patients in SGEM#324 (we don’t yet want to use spirometry to aid discharge decisions in patients with rib fractures), SGEM#212 (increasing age, more rib fractures, more underlying disease and poor oxygenation are risk factors for poor outcome in older patients with chest trauma) and in SGEM#89 in 2014 when we first concluded that identifying older patients at risk of falls is really tricky. CLINICAL QUESTION: DOES FFP:PRBC RATIO IN MASSIVE TRANSFUSION FOR TRAUMA AFFECT SURVIVAL IN OLDER ADULTS? Reference: Hohle et al. Massive Blood Transfusion Following Older Adult Trauma: the Effect of Blood Ratios on Mortality. AEM December 2022 Population: Patients aged 65 or older receiving massive blood transfusion from American College of Surgeons Trauma Quality Improvement Programme National Trauma Data Bank 2013-2017. Massive transfusion was defined as >=10 units of pRBCs in 24 hours or >=5 units within 4 hours of ED admission. Excluded: Patients who were dead on arrival at ED, patients who received no plasma, and those who received more plasma than red cells. Intervention: 1:1 ratio of FFP to pRBC Comparison: 1:2 or lower ratio of FFP to pRBC Outcomes: Primary Outcome(s): 24-hour and 30-day mortality Secondary Outcomes: Hospital and ICU length of stay, ventilator days, complications and need for emergency surgery for haemorrhage control. Type of Study: Observational cohort study Dr. Rae Hohle This is an SGEM HOP and we are pleased to have the lead author on the show. Dr. Rae Hohle is a PGY1 in Emergency Medicine at Regions Hospital in St. Paul, MN. She has a background in computer science and with the support of her program has been able to continue to work on research projects in re...