In this episode we go back to the treatment of massive hemorrhage, not just trauma, but also OB with post-partum hemorrhage and GI bleeds. We touch on massive transfusion protocols and all the stuff that goes with them. We go over the Eight “Ts” of Massive Hemorrhage Protocols, with a special emphasis on rural centers. I am joined by returning guest:

Andew “Petro” Petrosoniak, MD

Andrew Petrosoniak, MD, MSc (MedEd), FRCPC is an Emergency Physician & Trauma Team Leader, Lead of the Translational Simulation & Clinical Integration at St. Michael’s Hospital, an Assistant Professor at the University of Toronto, an Associate Scientist at the Li Ka Shing Knowledge Institute and Co-Principal, Advanced Performance Healthcare Design. Find him on the web at: advancedperformance.ca or on the hellhole that is twitter at @petrosoniak.

Triggers

When to activate the MHP Delayed activation is OK. Default to 2–3 RBCs first, then reassess. Use “ABC after 3” approach.

RABT

Critical Administration Threshold

Shock Index

Intermediate Pack–what’s in it, no reason for all RBCs

[] 2022 study that shows no harm from early red

Obstetrics

Give us what you got

Team

Roles, leadership, communication Set resus targets early. Assign blood product flow to team members. Use shared mental models.

Doc on the transfuser

Transfuse Products

1:1 vs. 2:1

Bayesian Analysis of PROPPR

Shoot for 1:1

PLT

Fibrinogen

What is your transfusion trigger?

Blood Pressure Goal–adapt for transfer, for intubation. 80-90, 100 for head injury transfer intubation

Whole Blood–Petro doesn’t have it yet

Catch-Up PCC

Early PLT

Early Fibrinogen–is your need for fibrinogen based on a deficient FFP transfusion issue

Calcium

Vasopressin

GI Bleeds-AVB, not GI bleeding

Baveno VII

Crystalloid

Higher than trauma

Do not correct based on intial INR

Obstetric

Fibrinogen

REBOA

Rural Environment

Should we be stopping at rural hospitals?

Presented at AAST-FIRST2 Trial

After First 2 packs:

2000 U PCC and 4 G Fibrinogen Concentrate

May Repeat x 1 at the 30-60 minute mark if they are still there

Testing

Labs & frequency Hourly labs: CBC, INR, fibrinogen, ionized calcium, lactate. Don’t forget fibrinogen.

Q1 hour

POC

PT/PTT

TXA

Tranexamic acid use Trauma: 2g early. Time CutOff – they still use 3 hrs, I really want it in within 1 hour to 90 minutes

PPH: 1g then repeat.

GI: avoid—can cause harm.

Head Injury: Crash3 is ambiguous, Petro gives it, I do not

Temperature

Avoid hypothermia Warm blankets + prehospital warm-up.

Targets

Lab thresholds Hb >7, INR <1.8, Plt >50 (or >100 in ICH), Fibrinogen >1.5–2.

Termination

When to stop MHP

Reassess every 30 min.

Avoid premature deactivation. ICU vigilance post-MHP.