Hematology Oncology · Year 2 · from Hematology Oncology
Case 3: Massive Transfusion Protocol
Patient Presentation
Demographics: 32-year-old male
Chief Complaint: Major trauma from motor vehicle collision
History of Present Illness: The patient was the unrestrained driver in a high-speed motor vehicle collision. He is brought to the trauma bay hypotensive and unresponsive. He has obvious abdominal distension and unstable pelvic fracture. Estimated blood loss is significant.
Initial Assessment:
- Airway: Intubated in field
- Breathing: Mechanical ventilation, bilateral breath sounds
- Circulation: BP 62/40 mmHg, HR 142 bpm, cool extremities
Workup and Results
Initial Labs:
- Hemoglobin: 5.2 g/dL
- Platelets: 68,000/mcL
- INR: 2.1
- Fibrinogen: 85 mg/dL
- pH: 7.18 (acidosis)
- Lactate: 8.2 mmol/L
FAST Exam:
- Large amount of free fluid in abdomen
Clinical Image
Diagram illustrating massive transfusion protocol with balanced 1:1:1 ratio of packed red blood cells, fresh frozen plasma, and platelets, designed to replace whole blood and prevent dilutional coagulopathy.
Diagnosis
Hemorrhagic Shock Class IV with Coagulopathy Requiring Massive Transfusion
Criteria for massive transfusion protocol activation:
- Anticipated need for >10 units pRBC in 24 hours
- Hemodynamically unstable with ongoing bleeding
- Blood loss >50% blood volume
Discussion
This case illustrates massive transfusion principles:
- Definition: The lecture defines massive transfusion as 10 or more units of packed red blood cells in 24 hours, or replacement of entire blood volume.
- 1:1:1 Ratio: The lecture describes the recommended ratio of 1:1:1 for pRBC:FFP:platelets, designed to approximate whole blood and prevent dilutional coagulopathy. The PROPPR trial supported this balanced approach.
- Emergency Release: The lecture explains that when blood type is unknown in emergencies, O-negative blood (universal donor for RBCs) should be given. For women of childbearing age, Rh-negative is preferred to prevent Rh sensitization.
- Hypothermia Prevention: The lecture notes that massive transfusion contributes to the "lethal triad" of hypothermia, acidosis, and coagulopathy. Blood warmers and active warming are essential.
Treatment Plan
- Activate Massive Transfusion Protocol:
- 1:1:1 ratio pRBC:FFP:platelets
- Blood bank prepares "cooler" with balanced products
- Initial Resuscitation:
- 2 units O-negative pRBC immediately (or type-specific once available)
- Tranexamic acid 1g IV bolus (within 3 hours of injury)
- Calcium supplementation (citrate-induced hypocalcemia)
- Blood Products:
- Continue balanced transfusion
- Use blood warmer for all products
- Cryoprecipitate if fibrinogen <150 mg/dL
- Surgical Control:
- Emergent laparotomy for hemorrhage control
- Damage control surgery principles
- Monitoring:
- Serial labs every 30-60 minutes
- Viscoelastic testing (TEG/ROTEM) if available
- Temperature monitoring
- Prevent Lethal Triad:
- Active warming
- Correct acidosis with resuscitation
- Replace clotting factors
Teaching Points
- Massive transfusion defined as ≥10 units pRBC in 24 hours
- Use 1:1:1 ratio (pRBC:FFP:platelets) for balanced resuscitation
- O-negative blood for emergency when type unknown (O Rh-negative for women of childbearing age)
- Prevent lethal triad: hypothermia, acidosis, coagulopathy
- Tranexamic acid within 3 hours reduces mortality in trauma
Image Reference
For visual reference of transfusion medicine concepts, see:
- Radiopaedia: Transfusion reactions - Overview
- Wikipedia: Blood transfusion - Components
- Radiopaedia: TRALI - Imaging
Learning Points
- AHTR Prevention: Clerical error is #1 cause - always verify patient ID at bedside
- TACO vs TRALI: Elevated BNP and hypertension = TACO; hypotension = TRALI
- Massive Transfusion: 1:1:1 ratio (pRBC:FFP:platelets) approximates whole blood
- Emergency Blood: O-negative for unknown type; O Rh-negative for women of childbearing age
- Stop and Report: Always stop transfusion immediately when reaction suspected