Massive transfusion is defined as transfusion of more than ten units of packed red cells over 24 hours or four units within one hour.
The early administration of fresh frozen plasma and platelets helps to reduce the overall requirement for packed red cell transfusion
There has been a more in recent years towards restricted fluid resuscitation rather than standard fluid resuscitation.
Duke et al reported on a retrospective analysis of 307 patients admitted to a level 1 trauma centre with penetrating torso injuries and a systolic blood pressure of less than 90mmHg who were managed by damage controlled resuscitation and surgery.One group received standard fluid resuscitation(SFR) the other group restricted fluid resuscitation(RFR).The SFR group had a higher intraoperative mortality(32% versus 9%) and overall mortality rate (37% versus 21%).The higher mortality was attributed to the effect of a large volume of fluid in diluting clotting factors and reducing blood viscosity and the increased blood pressure.RFR was beneficial in that it provided patients with permissive hypotension(systolic blood pressure of 90)until damage control surgery was achieved.
Massive transfusion protocol
The activation criteria for every MTC varies slightly but in general is based on markers of haemodynamic hypovolaemic shock
The use of tranexamic acid to reduce the amount of bleeding in trauma patients is now well established
The crash 2 study was a randomized prospective multicentre control trial performed in 274 hospitals in 40 countries involving 20,211 patients.
Patients were randomized to being given tranexamic acid (TXA) or placebo.
The effect of TXA on death, thromboembolic events and blood transfusion requirements in trauma patients was recorded.
Administration of TXA was in two doses; 1 g over 1 hour and a further 1 g infused over 8 hours. The data showed that the administration of TXA was a time-critical intervention. Data from the group treated within one hour showed the most dramatic benefit, with the risk of death reduced from 7.7% to 5.3% in the treated group.
The study found that traexamic acid reduced the risk of death in trauma patients. Most benefit was seen in the group sustaining penetrative trauma.
No increase in thromboembolic events were noted and the risk of adverse events was low. As such the recommendation was that TXA be administered to all severely traumatized patients who have a significant bleeding risk.
Damage control orthopaedics
The concept of damage control orthopaedics evolved from its use in abdominal surgery. A systematic 3-phase approach was used to disrupt the lethal cascade of events that lead to death by exsanguination.
Phase 1 involved immediate laparotomy to control haemorrhage and contamination. Phase 2 was resuscitation in the ITU with improvement of haemodynamic parameters, correction of coagulation defects and rewarming. Phase 3 consisted of re-operation, removal of abdominal packs, definite repair of abdominal injuries and closure.
This was extended to orthopaedic practice.