1. Rachel Hawes RVI Northern trauma network conference March 2014 Major Haemorrhage Policy for Trauma

2. Background Leading cause of traumatic death Advances in haemostatic resuscitation Balanced transfusion 1:1:1:1 Introduction of MHP Questions – How many major haemorrhage pt? – Frequency of Acute Coagulopathy of Trauma (ACoT) – How effective is our MHP?

3. RVI Major Haemorrhage Policy Standardise blood product use Reduce logistical delay Prehospital initiation Pre-thawed FFP – avoid delay in receiving balanced transfusion

4. Audit Inclusions – All trauma patients to RVI – April 2012 - April 2013 – >18 yrs – Activation of MHP – Or >4 products in 1 hr Exclusions – Children – Preceding medical event – Transfers via Trauma Units Data Collection – Injury Severity Score (ISS) – TARN Predicted Survival – Actual 30 day mortality – Presentation - Hb, PT, Fib – Products Transfused – Post MHP - Hb, PT, Fib

5. Results - How much trauma do we get? April 2012 - April 2013 935 trauma calls 899 TARN patients – RTA – Assault – Fall Frequent of major haemorrhage? 51 MHP Patients (5.6%)

6. Injury Severity Score v Mortality

7. Mortality - Standard Trauma Pt v MHP Pt

8. ISS versus Predicted & Actual Outcome

9. Coagulopathy

10. ACoT on Presentation in ED? Fibrinogen on presentation Fibrinogen <1.5 = 21% PT on presentation PT> 18 = 16%

11. Is ACoT due to Prehospital Fluid? No correlation between fluid volumes given and – Hb on presentation – PT on presentation – Fib on presentation

12. Presence of Coagulopathy Post MHP Post MHP Fib <1.5 = 0% (Data for 33 Pt) Post MHP PT > 18 = 3% (Data for 29 Pt)

13. Hb on Arrival v Post MHP Hb on arrival <8.0 = 6.8% Over and under transfusion Hb post MTP <8.0 = 5.8%

14. The Future Over and under transfusion – Deviation from policy – Timing of lab results – Lack of Point of Care testing - guide treatment Potential role of ROTEM/ TEG Prehospital Transfusion

15. Limitations Early deaths after presentation Unable to get bloods Included in ISS calculations but excluded for comparison of lab data

16. Summary Trauma - Mortality proportional to ISS 5% of patients have major haemorrhage Increased mortality ass with major haemorrhage 20% established ACoT on arrival – Not related to prehospital fluid administration MHP effective in treatment and prevention of ACoT Future – POCT – TEG or ROTEM – ‘Blood on Board’ HEMS

17. Questions?