MASSIVEHAEMORRHAGEPOLICY

ABMUHBTransfusionTeam

Objec@ves

§  Todefinetheresponsibili@esandrolesoftheClinicalteamandtheHaematologyDepartmentinthemanagementof‘MASSIVEHAEMORRHAGE‘

§  Todescribetheprocessfordeliveringthetransfusion(includingprescribingandcheckingbloodproducts)

§  Toreviewuseoftranexamicacid

KeyPrinciplesremainthesameasothermajoracuteevent

communica@on

AppropriateAssessmentbyadoctor

Ac@vate

Delegaterole(teamleader)*

Implement

Pa@entAc@va@on/Review

communica@on

AppropriateReassessment

Con@nueorde-ac@vate

Nominatedleadchangesonpttransfer

Con@nueorde-ac@ve

REMEMBER!!TELLBLOODBANK

CriteriaforAc@va@on

•  SystolicBP<90mmHgand/orpresenceofinadequate@ssueperfusion+evidenceofsignificantchest/abdomen/pelvic/longbonetrauma.•  Caveats:children,elderly,co-morbidi@es.•  Ideallybeforepa@entsarrives

Defini@onofongoingMassiveHaemorrhage

§ MassiveHaemorrhagemaybedefinedasthelossofonebloodvolumeovera24hourperiod.....

§  Orintheacutesitua@on.......§  50%bloodvolumelossin3hours,Or

§  Bloodlossatarate>150mlperminute

Organisa@onandresponsibili@es

§  TheClinicalTeamLeaderdetermines‘MASSIVEHAEMORRHAGEsitua@on’

§  TheywillnominateateammemberwhowillcontactSwitchboard,givingdetailsof:Ø ClinicalareaØ Acontactname(teamleader)*Ø Contacttelephonenumber.

Tono4fy:§  Bloodtransfusionlaboratory(oroncallBMS)§  PorterSupervisor§  Relevantseniormedicalstaff§  ConsultantHaematologistoncallRelaytotheabove:Ø ClinicalAreaØ AcontactnameØ Contacttelephonenumber

RoleofSwitchboard

ClinicalResponsibili@esofteamleader/seniornurse

§  Ensurethepa@enthasauniqueiden@fierorNHSnumber

§  Ensurecorrectbloodsamplesandrequestformsaresentimmediately:

Ø FBC/biochemistryscreenØ GroupandsaveØ Coagula@onscreen

Informa@onrequirementsforpre-transfusiontes@ng–knownpa@ent

§  UniqueIden4fierHospital/NHS?/EDnumber

§  Lastname

§  Firstname

§  DateofbirthAgeisnotenough

§  AddressMinimumfirstline

§  RequesterIDSignatureofsampletakeranddateand4meofcollec4onINURGENTSITUATIONSINFORMATIONREQUIREMENTSARETHESAME

Informa@onrequirementsforpre-transfusiontes@ng–unknownpa@ent

•  Hospital/EDnumber•  LastnamestatedasUNKNOWN•  Firstnameforexample:Male1/Female3•  Indica@onofage–child,youngadult,elderly•  The@meofadmission•  Signatureofsampletaker

Responsibili@esoftheBloodTransfusionStaff

§  Thelabcontactsthenamedpersonintheclinicalareatoestablishpa@entcriteria.

§  ThelabassumesthattheemergencyORh(D)Nega@veunitsintheissuefridgehavebeentaken(unlessotherwisespecificallyno@fiedbytheassessingclinician)

§  Thelabwillissue:Ø Afurther4unitsofORh(D)Nega@veblood(ORh(D)posi@vedependingonavailability)

Ø 4unitsofFreshFrozenPlasma(FFP)willbeissued.

•  NotallOnegBloodiswithoutrisk

•  If @me allows and you are able to do agroupandsave(approx20mins) theLabwillbeabletoprovidebloodspecifics

The ultimate responsibility for use of any component lies with the Clinical Team/ Consultant Haematologist

SuitabilityofBlood

RoleofthePorters

§  Adedicatedporterwillbeiden@fiedandsenttothebloodtransfusionlaboratorytocollect:

Ø 4unitsofemergencyORh(D)Nega@veforimmediateuse.Socalled‘flyingsquadblood’

§  Theporterwillthen:Ø Collect4unitsofbloodand4FFP(MHP)Ø Delivergroupingbloodsamplesrequesttolab

Informa@onquality

Inadequatelylabelledsamplesandrequestformswillbediscarded

TransfusionDetails•  BloodMUSTbewarmed.•  Inshockedpa@entsBLOODisfirstlinetreatmentNOT

crystalloid.•  Givebloodthroughthick/shortline(Traumaline).•  Thetraumaleaderisresponsiblefor“standingdown”the

MHPandensuringthattheOnegbloodisbackinbloodbankin30minutes.

•  CheckHaemoglobin,Potassium,CalciumandClonngaoertransfusionoffirstbloodseries

•  Give10ml10%calciumchlorideaoerfirst4Ublood•  MHPac@va@oncanoccuratany@meincludingbasedon

pre-hospitalvitals/mechanism

TRANEXAMICACIDINTRAUMA

Whatistranexamicacid?

•  Itisanan@-fibrinoly@c•  Fibrinprovidesthe‘skeleton’oftheclot•  Plasmindegradesfibrin•  Tranexamicacidstopstheac@va@onofplasminfromplasminogen

•  Sotranexamicacid‘protects’theclot

Research

•  CRASH2trialused>20,000pa@entsandfoundthat“allcausemortalitywassignificantlyreducedwithtranexamicacid.”

•  “Riskofdeathfrombleedingsignificantlyreduced”

•  Mainrisk:vascularocclusion(Myocardialinfarc@on,pulmonaryembolismandstroke)

Whyusetranexamicacid?

•  Toreducetheriskofdeathduetobleedingintrauma.

•  Itisusedinaddi@ontostandardresuscita@onandshouldnotbeusedasasubs@tuteforsurgicalinterven@ontocontrolbleeding.

•  Purposeistostabilisetheclotinthecontextofdamagecontrolresuscita@on(keepthesystolicBPat90mmHg.)

Prescribing

•  ConsultantormiddlegradedirectedbyTTL•  1gTranexamicacidIVbolus(maybegivenIO).FLUSHthelinebeforegivingblood

•  Repeat(samedose)aoerEVERY10UnitsofBloodProducts(eg:6unitspackedredbloodcellsand4unitsFFP)

•  Paediatricuseunprovenbutconsider•  PaedsDosage:15mg/Kgtoamax1gover10mins

•  ItiskeptintheTRAUMADRUGpack&drugcupboard

Indica@onsforuse

• Adulttraumapa@ent• Considerinchildren• Within8hoursofinjury• Significanthaemorrhage

–  BP<90SYSTOLIC,PULSE>110–  RISKOFSIGNIFICANTHAEMORRHAGE(COMPENSATEDSHOCKORRE-

BLEEDING)

Managementofhaemorrhage

•  Damagecontrolresuscita@on•  Primarysurveytheatre•  Massivehaemorrhagepolicy•  Tranexamicacid

FlowchartforMassiveHaemorrhageProtocolClinicalAreaTEAMLEADERMUSTDECLARE

MassiveHaemorhage-clinicalareaif:Clinicalevidenceofsuspectedmassivehaemorrhage

Nominated member of team 1.  Generate emergency ID number for patient 2.  Call switchboard – Notify massive haemorrhage-

clinical area and request Senior support 3.  Send porter for ‘Emergency Blood’

4 units

SwitchboardsendoutMassiveHaemorrhage-clinicalarea-Alertbloodbankbyphone(day)orbleep(OOH),PortersLodge,

appropriateSpecialistConsultantandConsultantHaematologist

TakebaselinebloodsamplespriortotransfusionIncludingFBC,crossmatch,CloVngscreenandfibrinogenSendporterdirecttolabwithsamplesAndtocollectFFPx4plusONegRedcellsx4

ImmediateTransfusionGiveEmergency:• ONegredcellsx4units• 4unitsFFP• andfurther4ONegunitsredcells

Ifbleedingcon4nues–ContactlabtoinformofneedforongoingsupportSendportertocollect:• 4unitsredcell,groupspecific,• 4unitsFFP,• 1plateletpool,• Fibrinogenconcentrate4gms

• REPEATFBCANDCLOTTINGSCREENAdministerfurtherproductsif:

• Platelets<80x109/l–1poolplatelets(2if<30)• Fibrinogen<2.0g/l–4gmsfibrinogen

• APTT/PTra4o>1.5xnormal–6units(1.5litre)FFP

Immediateassessmentofcauseofbleedingandappropriatemanagement

Seniorreviewofmanagementplanand

appropriateinterven4ontoarrest

bleeding

Laboratoryprotocol:‘MassiveHaemorrhage’

CallforassistanceAssumeOnegused

Thaw4AFFPIssue4ONeg(emergencyuse)RestockemergencyONegEnsurePlateletsavailableCheckfibrinogenavailable

NinestepsforSuccessfulCo-ordina4oninMassivehaemorrhage(adults)

1.  Recognisetriggerandac@vatepathwayformanagementofmassivehaemorrhage.

2.  SendPorterfor‘Emergencyblood’4units.

3.  Allocateteamroles.4.  Completerequestforms/takeblood

samples-labelsamplescorrectly/re-checklabellingbeforedispatch.

5.  Communica@onleadtobecontactedbyBMS(no@fiedbyswitchboard).

6.  Requestbloodproducts.7.  Effec@vecommunica@onbetweenthe

laboratoryandclinicalarea.8.  CommunicateSTANDDOWNof

pathwaytoLaboratoryandPorters.9.  Ensuredocumenta@oniscomplete.

LABBMSCONTACTMorristonExt3054duringcorehours(08.45-20.00&Saturday8.30-12.30)Bleep3914Outofhours(Saturday12.30-08.45Monday)BleepviaswitchboardifnoanswerSingletonExt5075duringcorehours(08.45–20.00&Saturday8.30-12.30)Bleep5716Outofhours(Saturday12.30-08.45Monday)BleepviaswitchboardifnoanswerPOW2585/2343Bleep253OOHNPT2367PORTERCONTACTSMorristonBleep3916Ext3098SingletonBleep5643Ext5372POWBleep270Ext2481Cisco6270NPTBleep2921Ext7750

REMEMBER ZERO TOLERANCE ON INADEQUATE LABELLING

IDENTIFIERS

SUMMARY.

•  Criteriaforac@va@onofmassivehaemorrhagepolicy

•  Rolesandresponsibili@es•  ACCURATEIDENTIFICATION,COMMUNICATIONANDREVIEW

•  Useoftranexamicacid