Blood Management in the Orthopaedic Trauma Patient

Wade Gofton, M.D., FRCSC
Steve Papp, M.D., FRCSC
Ottawa, ON

Trauma is the leading cause of life lost years in North America, and uncontrolled hemorrhage is the leading cause of potentially preventable death. The timing and means of intervention is important, because hemorrhagic death typically occurs very early, usually within the first six hours of admission1. Trauma patients presenting with shock and coagulopathy on admission receive massive transfusions and suffer increased mortality: ranging from 40-70% at leading trauma centres2,3. With increasing experience in both civilian and military trauma, there has been a re-evalaution of transfusion practices and blood conservation techniques have been introduced in the acutely traumatized patients.

 

During the resuscitation of the orthopaedic trauma patient one needs to focus on assessment of the volume status, the prevention of ongoing losses and the timing of blood replacement to restore tissue perfusion and hemodynamic stability.

Assessment of Volume Status
Assessment of the patients' mental status, blood pressure, blood pressure differential, heart rate, and urine output can all help in estimating volume status. One must be aware of potential loss associated with pelvic and long bone fractures (pelvis >1.5L, femur >1L) and open fractures, especially if the patient is hypothermic or there has been a prolonged extrication or transfer. Early identification of hypovolemia and appropriate fluid resuscitation, including blood replacement when indicated, can be key factors in the reduction of ongoing losses and mortality.

Prevention of Ongoing Loses

Many of the important factors in the prevention of ongoing losses are key elements in the ATLS protocol. Following the assessment of the airway and breathing is the assessment of circulation and the identification of arterial bleeding or significant losses. Clamping of identifiable bleeding arteries or the use of a tourniquet (field tourniquet, blood pressure cuff or pneumatic tourniquet) can reduce arterial loss4. The realignment and stabilization of pelvic and long bone injuries and the application of gauze and direct pressure can help minimize non-arterial losses.

The restoration and maintenance of normothermia is also essential in reducing blood loss. A recent meta-analysis demonstrated that even mild hypothermia (< 1°C) can increase intra-operative blood loss by approximately 16% (4-26%) and increases the relative risk of transfusion by approximately 22% (3-37%)5. Other treatment considerations to reduce ongoing losses can be thought of as systemic or local treatment options. Systemic options include cell salvage or the administration of fibrinogen or transexamic acid while local treatment options include a variety of applied hemostatic agents (collagen, cellulose-based products, gelatin, fibrin or synthetic glues and adhesives).

The use of cell saver in the setting of trauma remains controversial. There is concern about the spread of infection from potentially contaminated wounds and the risk of potentiating a coagulopathy in a patient who is already systemically challenged. When there exist few other options, and in cases of massive blood loss into a body cavity without significant contamination or in the setting of urgent surgery with anticipated significant blood loss (spinal surgery), blood salvage may be of value6.

Transexamic acid is a synthetic lysine analogue that is a competitive inhibitor of plasmin and plasminogen. A recent guideline suggested that it be given to the trauma patient as a bolus of 10 ml/kg (with consideration of an infusion of 1-5 ml/kg per hour until bleeding is controlled) based on the assumption that its clear benefit in the elective patient is transferable to the trauma patient4. The theoretical risk of transexamic acid potentiating thrombosis has been a major concern in orthopaedic elective and trauma patients who are already at significant risk. However, a Cochrane review has not demonstrated any increase risk of thrombosis associated with its use7. The multicentre CRASH II randomized over 20000 trauma patients in 40 countries to the early use of transexamic acid versus a placebo8. The use of transexamic acid reduced the risk of death due to bleeding (RR-0.68) if given within the first hour and (RR-0.71) if given between hour one and three. The authors conclude that transexamic acid should be given as early as possible in the trauma patient.

Other systemic agents include factor VII and fibrin. Factor VII is not considered a first line agent but is also used occasionally in the bleeding patient when all other factors are optimized4. Administration of fibrin (2g) given with intra-operative bleeding9 results in decreased operative blood loss and transfusion requirements10.

Timing of Replacement
Excessive early fluid loading prior to control of losses can increase the risks of mortality, abdominal compartment syndrome, hypothermia and significant coagulopathy. It is suggested that minimizing fluid resuscitation and allowing 'permissive hypotension' with the maintenance of a mean arterial pressure > 65 mm Hg until the source of major bleeding has been controlled is of benefit4.

Serial assessment of the vital signs and haemoglobin/hematocrit is of value in following patient status (blood levels and loss), need for replacement and response to resuscitation. The haemoglobin level should be maintained between 70 to 90 /dl. Traditionally, trauma patients who have been serially resuscitated with large volumes of crystalloid and/or colloids with failure to respond, receive transfusions of red blood cells followed by smaller amounts of plasma and platelets (haematology). However recent military experiences suggest that mortality may be significantly reduced with more aggressive transfusion ratios11. In an effort to better determine the ideal ratios for pRBC, FFP, and platelet replacement a prospective observational multi-centre massive transfusion study (PROMMTT study) at 10 trauma centres has been undertaken.

In cases with significant blood loss, or significant coagulopathy (INR > 1.5), the early use of thawed FFP is indicated. Previous recommendations were to initiate FFP transfusion (10-15 ml/kg) after the requirement of 10 units of pRBC (1:10). Based on military data, the use of a higher FFP to pRBC ratio (2:3) may be of value in the management of civilian trauma associated with significant blood loss12,13. It is also recommended in the setting of significant blood loss that platelets be transfused to maintain a platelet count of > 50 x 109/L4. In patients with severe bleeding or a traumatic brain injury, maintenance of a platelet count > 100 x 109/L is indicated4.

In the event of massive transfusion, calcium ion levels should be carefully monitored, and calcium chloride should be given to avoid the potential risk of arrythmias.

Conclusion
It is essential to quickly evaluate the trauma patients' volume status, potential sources of loss and to control ongoing blood loss. Resuscitation should begin immediately but evidence suggests crytalloid and colloid use should be controlled. The goal is to maintain the MAP > 60 mm Hg with more aggressive resuscitation following the control of losses. Earlier use of both blood and FFP, and the administration of transexamic acid may also be of value in improving the outcomes in the orthopaedic trauma patient.

References

  1. Demetriades D., Murray J., Charalambides K., et al. Trauma fatalities: time and location of hospital deaths. J Am Coll Surg. 2004;198:20-26.
  2. Hess J.R. Blood and coagulation support in trauma care. Hematology Am Soc Hematol Educ Program. 2007;187-191.
  3. Holcomb J.B., Wade C.E., Michalek J.E., et al. Increased plasma and platelet to red blood cell ratios improves outcome in 466 massively transfused civilian trauma patients. Ann Surg. 2008;248:447-458.
  4. Rossaint R., Bouillon B., Cerny V., Coats T.J., et al. Management of bleeding following major trauma: an updated European guideline. Critical Care 2010. http://ccforum.com/content/14/2/R52, accessed April 27 2011.
  5. Rajagopalan S., Mascha E., Na J., Sessler D.I. The effects of mild perioperative hypothermia on blood loss and transfusion requirement. Anesthesiology. 2008 Jan;108(1):71-7
  6. Rubens F.D., Mujoomdar A., Tien H.C., Cell Salvage in Trauma. International Trauma Care (ITAACS) Vol 18:1, 2008.
  7. Henry D.A., Moxey A.J., Carless P.A., O'Connell D., McClelland B., et al. Anti-fibrinolytic use for minimising perioperative allogeneic blood transfusion. Cochrane Database Syst Rev 2001.
  8. CRASH-2 II collaborators. The importance of early treatment with tranexamic acid in bleeding trauma patients: an exploratory analysis of the CRASH-2 randomised controlled trial. Lancet 377 2011: 1090-1016.
  9. Karlsson M., Ternstrom L., Hyllner M., Baghaei F., Nilsson S., Jeppsson A. Plasma fibrinogen level, bleeding, and transfusion after on-pump coronary artery bypass grafting surgery: a prospective observational study. Transfusion 2008, 48:2152-2158.
  10. Fenger-Eriksen C., Lindberg-Larsen M., Christensen A.Q, Ingerslev J., Sorensen B. Fibrinogen concentrate substitution therapy in patients with massive haemorrhage and low plasma fibrinogen concentrations. Br J Anaesth 2008, 101:769-773.
  11. Holcomb J.B. Optimal Use of Blood Products in Severely Injured Trauma Patients. Hematology Am Soc Hematol Educ Program 2010, 2010:465-469.
  12. Borgman M.A., Spinella P.C., Perkins J.G., Grathwohl K.W., Repine T., Beekley A.C., Sebesta J., Jenkins D., Wade C.E., Holcomb J.B. The ratio of blood products transfused affects mortality in patients receiving massive transfusions at a combat support hospital. J Trauma 2007, 63:805-813.
  13. Spinella P.C., Perkins J.G., Grathwohl K.W., Beekley A.C., Niles S.E., McLaughlin D.F., Wade C.E., Holcomb J.B. Effect of plasma and red blood cell transfusions on survival in patients with combat related traumatic injuries. J Trauma 2008, 64:S69-77, discussion S77-78.
 

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