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Trauma and Acute Bleeding

Learn more about trauma and the patient burden

Trauma is the third leading cause of death in the United States1and leading cause of death worldwide among persons aged 5‐44 years.2 One of the most common mechanisms of injury is motor vehicle crashes, and one of the most common causes of death involves hemorrhagic shock due to severe bleeding.3 An average adult has approximately 10 units of blood in his/her body, but a single car accident victim can require as many as 100 units of blood.4

Patients in hemorrhagic shock undergo damage control resuscitation which can include administration of RBCs, plasma, and platelets in a 1:1:1 ratio as well as damage control laparotomy.5 Some patients require massive blood transfusion which is most commonly defined by transfusion of >10 units of PRBCs in the first 24 h after trauma.6,7

As RBCs age, they undergo biochemical and metabolic changes due to storage lesion and oxidative damage.8 Recent studies have shown that transfusions of older RBCs at high volume are associated with increased in‐hospital morbidity and mortality and have been linked to increases in hospital‐acquired infections and thrombotic events.9,10

1. Kochanek et al. Mortality in the USA, 2016. NCHS Data Brief, No. 293, December 2017. 2. Corradi et al. Hemorrhagic Shock in Polytrauma Patients: Early Detection with Renal Doppler Resistive Index Measurements. Radiology 2011; 260 (1). 3. Tisherman et al. Detailed Description of all Deaths in Both the Shock and Traumatic Brain Injury Hypertonic Saline Trials of the Resuscitation Outcomes Consortium. Ann Surg 2015; 261 (3). 4. American Red Cross. Facts About Blood Supply. https://www.redcrossblood.org/donate‐blood/how‐to‐donate/how‐blood‐donations‐help/blood‐needs‐blood‐supply.html. Accessed January 2021. 5. Holcomb et al. Transfusion of Plasma, Platelets, and Red Blood Cells in a 1:1:1 vs a 1:1:2 Ratio and Mortality in Patients with Severe Trauma: The PROPPR Randomized Clinical Trial. JAMA 2015; 313 (5). 6. Fraga, G. Transfusion of Blood Product in Trauma: An Update. The Journal of Emergency Medicine, 2010; 39(2), 253‐260. 7. Como, J. Blood transfusion rates in the care of acute trauma. Transfusion, 2004, June; Volume 44, 804‐813. 8. Yoshida et al. Red Blood Cell Storage Lesion: Causes and Potential Clinical Consequences. Blood Transfus 2019; 17: 27‐52. 9. Johnson et al. Morbidity and Mortality after High‐dose Transfusion. Anesthesiology. 2016 February; 124: (2). 10. DeSantis et al. Characterizing Red Blood Cell Age Exposure in Massive Transfusion Therapy: the Scalar Age of Blood Index (SBI). Transfusion 2019; 59.

 

Hypothetical Profile

While driving home from work, a truck pulled out in front of Michael causing him to swerve and lose control of his motorcycle. Michael sustained multiple fractures and intra-abdominal injuries. While in the emergency department (ED), damage control resuscitation (transfusing 1:1:1 ratio of red blood cells, fresh frozen plasma and platelets) was initiated to stabilize him.

Michael spent 20 days in the hospital, suffered multiple complications which extended his hospital stay. He is finally back at home with a long path to recovery before he returns to work.

PRESENTATION UPON ARRIVAL AT ED

  • Pre-hospital chest decompression performed
  • Arrived in ED conscious and alert, but severely short of breath
  • Persistent hypotension and bilateral decreased breath sounds
  • Lactate level 7mmol/L

ED PROCEDURES AND TREATMENT

  • Intubation and bilateral chest tubes inserted
  • 1:1:1 resuscitation initiated via Rapid Infuser
  • FAST (Focused Assessment with Sonography in Trauma) exam positive for intra-abdominal blood

SURGERY

  • Continued 1:1:1 resuscitation and splenectomy performed
  • Orthopedic consultation for pelvic stabilization & femur fracture
  • Total: 12 units RBC; 10 units FFP; 2 platelet six-packs

OVERALL HOSPITAL STAY

  • Intubated 7 days for VAP (ventilator associated pneumonia)
  • ICU LOS (10 days); Hospital LOS (22 days)

Transfusion Related Complications

  • TRALI (transfusion related acute lung injury)
  • DVT (deep vein thrombosis)
  • ATN (kidney failure)

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