Massive Bleeding and Massive Transfusion

Abstract

Massive bleeding in trauma patients is a serious challenge for all clinicians, and an interdisciplinary diagnostic and therapeutic approach is warranted within a limited time frame. Massive transfusion usually is defined as the transfusion of more than 10 units of packed red blood cells (RBCs) within 24 h or a corresponding blood loss of more than 1- to 1.5-fold of the body's entire blood volume. Especially male trauma patients experience this life-threatening condition within their productive years of life. An important parameter for clinical outcome is to succeed in stopping the bleeding preferentially within the first 12 h of hospital admission. Additional coagulopathy in the initial phase is induced by trauma itself and aggravated by consumption and dilution of clotting factors. Although different aspects have to be taken into consideration when viewing at bleedings induced by trauma compared to those caused by major surgery, the basic strategy is similar. Here, we will focus on trauma-induced massive hemorrhage. Currently there are no definite, worldwide accepted algorithms for blood transfusion and strategies for optimal coagulation management. There is increasing evidence that a higher ratio of plasma and RBCs (e.g. 1:1) endorsed by platelet transfusion might result in a superior survival of patients at risk for trauma-induced coagulopathy. Several strategies have been evolved in the military environment, although not all strategies should be transferred unproven to civilian practice, e.g. the transfusion of whole blood. Several agents have been proposed to support the restoration of coagulation. Some have been used for years without any doubt on their benefit-to-risk profile, whereas great enthusiasm of other products has been discouraged by inefficacy in terms of blood transfusion requirements and mortality or significant severe side effects. This review surveys current literature on fluid resuscitation, blood transfusion, and hemostatic agents currently used during massive hemorrhage in order to optimize patients' blood and coagulation management in emergency medical aid.

Fig. 1

Definitions and key issues in trauma.

Fig. 2

Team players, elementary diagnostics, and their function in the trauma team.

Fig. 3

Factors leading to coagulopathy in massive bleeding.

Fig. 4

These key parameters should always be kept in the target range of normal or in specific target ranges to optimize coagulation. This also applies before special agents like factor VII are applied.

Fig. 5

The margination of thrombocytes might be an important effect in massive bleeding. This effect rather due to hydrodynamic forces rather than collisional forces or volumetric exclusion effects should lead to higher hematocrit values in acute bleeding situations. The upper panel shows well marginated thrombocytes at higher hematocrit values, whereas lower values lead to a distribution within the whole vessel (lower panel).

Fig. 6

Transfusion decision tree depending upon the actual/expected degree of blood loss.