BCotton, B.A, Podbielski, J., Camp, E., et al. (2013) Early Whole Blood Investigators: A randomized controlled pilot trial of modified whole blood versus component therapy in severely injured patients requiring large volume transfusions. Ann Surg ,258 (4), 527–532.Williams, J., Merutka, D., Bai, Y., et al. (2019) Safety profile and impact of low‐titer group O whole blood for emergency use in trauma. J Trauma Acute Care Surg , 88 (1), 87–93.2 When massive transfusion is indicated, the American College of Surgeons Trauma Quality Improvement Program currently recommends one unit of apheresis platelets to be given following the administration of how many units of packed red blood cells (PRBCs) in the setting of balanced component 1:1–1:2 (Plasma/PRBCs) resuscitation?12468Evidence currently supports a balanced transfusion strategy that targets a plasma:PRBC ratio approaching 1:1. There is no apparent increase in respiratory complications in the 1:1 group, despite prior retrospective associations between increased plasma transfusion and acute respiratory distress syndrome (ARDS). The latest massive transfusion guidelines from American College of Surgeons Trauma Quality Improvement Program (ACS‐TQIP) recommends a 1:1–1:2 (plasma/RBCs) transfusion ratio with one unit of apheresis platelets given for every 6 units of RBCs transfused.Answer: DCryer, H.G., Nathens, A.B., Bulger, E.M. (2014), American College of Surgeons Trauma Quality Improvement Program Massive Transfusion in Trauma Guidelines. facs.org/‐/media/files/quality‐programs/trauma/tqip/transfusion_guildelines.ashx.
3 A 75‐year‐old woman with cirrhosis arrives in the trauma bay after being hit by a car while crossing the street. Her initial work up revealed two left‐sided rib fractures and a grade 3 splenic laceration without evidence active extravasation. She is hemodynamically stable and her initial laboratory tests reveal a hemoglobin of 9.5 g/dL, hematocrit of 29%, platelet count of 125 000/mm 3 , and international normalized ratio of 3.1. While being managed nonoperatively in the intensive care unit, she becomes hypotensive. 1 unit of packed red blood cells (PRBCs) and 1 unit of fresh frozen plasma (FFP) are transfused. Shortly after the transfusions are completed, she develops tachycardia and dyspnea requiring supplement oxygen. Which of the following is the most diagnostic of transfusion‐associated acute lung injury (TRALI) as the source of her new oxygen requirement?Bilateral infiltrate on chest radiographyHeart Rate: 135PaO2/FiO2: 300Systolic Blood Pressure: 90Temperature 37.9The differential diagnosis of respiratory distress is broad in the setting of polytrauma, especially in those with known rib fractures and those requiring transfusions. Transfusion‐related acute lung injury (TRALI) is defined by the documentation of acute hypoxemia with PaO2/FIO2 ratio (P/F) of less than 300 mm Hg, bilateral infiltrates on chest radiograph (in the absence of left atrial hypertension), and the absence of acute injury before transfusion. In addition, onset of transfusion‐related acute lung injury is required to have occurred within 6 hours of the last transfusion. Transfusion‐associated circulatory overload (TACO) was defined as acute onset or worsening respiratory distress during or up to 12 hours after transfusion, plus evidence of acute or worsening pulmonary edema and volume overload. Signs/symptoms include fever, dyspnea, and hypotension. The treatment of TRALI is respiratory support, including measures to avoid worsening of lung injury. Transfusion of all types of blood products can cause TRALI. Pathogenesis is related to donor antibodies in the transfused blood and may also be related to modifications of stored blood. Measures to prevent TRALI include a restrictive transfusion policy, as well as blood bank measures such as predominant use of plasma from male donors.Answer: ASemple, J.W., Rebetz, J., and Kapur, R. (2019) Transfusion‐associated circulatory overload and transfusion‐ related acute lung injury. Blood , 133 (17), 1840–1853.
4 A 45‐year‐old man requires helicopter evacuation following a farming accident in which he was pinned under a peanut trailer experiencing crush injuries to his lower extremities. Transport time to nearest facility is approximately 35 minutes. His heart rate is 145 per minute, systolic blood pressure is 80 mmHg, and he appears confused. Prehospital providers obtained IV access and administered 1 L of crystalloid in the field. Repeat vitals en route demonstrate a heart rate of 125 and systolic blood pressure of 90. What additional resuscitation, if any, would offer the greatest survival benefit while traveling to the nearest hospital?Additional 1 L of crystalloid1 unit packed red blood cell (PRBC)1 unit fresh frozen plasma (FFP)1 unit PRBC + 1 unit FFPNo additional resuscitation requiredMore than one‐third of preventable deaths due to hemorrhage occur in the field. Evidence gathered from the Prehospital Air Medical Plasma Trial and its secondary analysis, patients with signs of shock should receive prehospital blood products whenever available. Crystalloid alone appears to be inferior to blood products and has a dose–response increase in mortality in this setting. If both PRBC and plasma are available, patients should receive both, as reduction in mortality has been demonstrated. If only 1 product can be added, plasma should be favored, as there is level 1 evidence to support it. The additive benefit of PRBC and plasma also suggests that there may be a benefit to the use of whole blood in the prehospital setting. Finding a balance between organ perfusion and hemostasis is critical when resuscitating a severely injured trauma patient. Answer E would allow for permissive hypotension which would not be advisable for this patient given that his mechanism may have also resulted in a traumatic brain and/or spinal cord injury which have yet to be ruled out. Permissive hypotension is not recommended in the setting of central nervous system injury.Answer: DGuette, F.X., Sperry, J.L., Peitzman, A.B., et al. (2019) Prehospital blood product and crystalloid resuscitation in the severely injured patient: A secondary analysis of the prehospital air medical plasma trial. Ann Surg. doi: 10.1097/SLA.0000000000003324.
5 Which of the following patients would receive the most benefit from administration of tranexamic acid (TXA)?25‐year‐old male with massive transfusion protocol activated approximately 9 hours post fall from height.80‐year‐old female with a nondisplaced pelvic fracture and stable vital signs on Warfarin.35‐year‐old male with massive transfusion protocol activated for hemodynamic instability 1‐hour after sustaining gunshot wounds to the chest.8‐year‐old male receiving 1:1 component resuscitation immediately following motor vehicle collision.65‐year‐old female with a history of stroke receiving 1:1 component resuscitation after being struck by a car.TXA is a synthetic derivative of the amino acid lysine that inhibits fibrinolysis by blocking the lysine binding site on plasminogen. In patients undergoing elective procedures, TXA has been shown to reduce the need for blood transfusion. The CRASH‐2 trial, a randomized, placebo‐controlled trial of TXA in trauma patients with significant bleeding, demonstrated a significant reduction in all‐cause mortality, as well as deaths due to hemorrhage, in the patients who received TXA within 3 hours. Trial results have been met with both enthusiasm and controversy regarding the application antifibrinolytics for patients with traumatic bleeding. As a consequence, several high‐quality randomized controlled trials are currently underway to help further elucidate the utility of TXA and other antifibrinolytics in traumatic injury, as well as other conditions with severe bleeding. Based on current evidence, TXA is most beneficial in the setting of trauma when empirically used in massive transfusion situations in those patients presenting within 3 hours of injury. Further trials are needed to refine and optimize TXA dosing regimens due to concern for seizures with higher dosing. There was no increase in vascular occlusive events in patients receiving TXA in the CRASH‐2 trial. However, history of or risk factors predisposing to thromboembolic events is considered a relative contraindication, as is the use of TXA in patients with subarachnoid hemorrhages owing to the association with increased cerebral ischemia. Although TXA has been studied extensively in the adult trauma patient, less evidence exists for children, and its use in the pediatric trauma population is not as widespread.Answer: CRamirez, R.J., Spinella, P.C., and Bochicchio, G.V. (2017) Tranexamic acid update in trauma. Crit Care Clin , 33 (1), 85–99.The CRASH‐2 Collaborators (2010) Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant hemorrhage (CRASH‐2): a randomized, placebo‐controlled trial. Lancet , 376 (9734), 23–32.
6 A 28‐year‐old man is taken emergently to the operating room for abdominal exploration after sustaining a gunshot wound to the right upper quadrant. On arrival, he was found to be in hemorrhagic shock and massive transfusion protocol was initiated. Intraoperatively, the bleeding is difficult to control, and diffuse oozing is noted as the case progresses.
