1. Cristy M. Thomas FNP-BC University of Nevada School of Medicine University Medical Center, Las Vegas NV Nevada’s Only Level 1 Adult Trauma, Level 2 Pediatric Trauma centers

2.  30-40 percent of trauma deaths are secondary to exsanguination  Causes of Coagulopathy in Trauma  Bleeding  Fluid Resuscitation  Transfusions-PRBC  Hypothermia  Multiple injuries

3.  Hypothermia  Acidosis  Progressive Coagulopathy

4.  Multifactoral  Dilution  Consumption of Platelets  Coagulation factor dysfunction of coagulation system

5.  Partial thromboplastin time (PTT)  Intrinsic Pathway  Prothrombin time (PT)  Extrinsic Pathway  Thrombin time  Common Pathway

6.  Fresh frozen plasma  Cryoprecipitate  Epsilon-amino-caproic acid (Amicar)  DDAVP  Recombinant human factor VIIa (Novoseven)

7. Source Platelet concentrate (Random donor) Each donor unit should increase platelet count ~10,000 /µl Pheresis platelets (Single donor) Storage Up to 5 days at room temperature “Platelet trigger” Bone marrow suppressed patient (>10-20,000/µl) Bleeding/surgical patient (>50,000/µl)

8. Transfusion reactions Higher incidence than in RBC transfusions Related to length of storage/leukocytes/RBC mismatch Bacterial contamination Platelet transfusion refractoriness Alloimmune destruction of platelets (HLA antigens) Non-immune refractoriness Microangiopathic hemolytic anemia Coagulopathy Splenic sequestration Fever and infection Medications (Amphotericin, vancomycin, ATG, Interferons)

9. Content - plasma (decreased factor V and VIII) Indications Multiple coagulation deficiencies (liver disease, trauma) DIC Warfarin reversal Coagulation deficiency (factor XI or VII) Dose (225 ml/unit) 10-15 ml/kg Note Viral screened product ABO compatible

10. Prepared from FFP Content Factor VIII, von Willebrand factor, fibrinogen Indications Fibrinogen deficiency Uremia von Willebrand disease Dose (1 unit = 1 bag) 1-2 units/10 kg body weight

11. Mechanism Prevent activation plaminogen -> plasmin Dose 50mg/kg po or IV q 4 hr Uses Primary menorrhagia Oral bleeding Bleeding in patients with thrombocytopenia Blood loss during cardiac surgery Side effects GI toxicity Thrombi formation

12. Mechanism Increased release of VWF from endothelium Dose 0.3µg/kg IV q12 hrs 150mg intranasal q12hrs Uses Most patients with von Willebrand disease Mild hemophilia A Side effects Facial flushing and headache Water retention and hyponatremia

13. Mechanism Activates coagulation system through extrinsic pathway Approved Use Factor VIII inhibitors in hemophiliacs Dose: (1.2 mg/vial) 90 µg/kg q 2 hr “Adjust as clinically indicated” Cost (70 kg person) @ $1/µg ~$5,000/dose or $60,000/day

14. Surgery or trauma with profuse bleeding Consider in patients with excessive bleeding without apparent surgical source and no response to other components Dose: 50-100ug/kg for 1-2 doses Risk of thrombotic complications not well defined Anticoagulation therapy with bleeding 20ug/kg with FFP if life or limb at risk; repeat if needed for bleeding

15.  Journal of Emergency Medicine 2009 April  Transfusion of Blood Products in Trauma: An Update  Massive Transfusion should be 1:1 Ratio  Restrictive Transfusion Protocols  Still in need of Prospective Randomized trials to standardize protocols

16.  Gonzalez et al. (2007) FFP should be given earlier to trauma patients requiring massive transfusions. Journal of Trauma. Jan 62(1) 112- 119.  Coagulopathies can be improved with strict protocols  1:1 PRBC to FFP

17.  Davis et al 2004  ICP monitor placement  157 patients in 3 groups  INR 0.8-1.2  INR 1.3-1.6  INR>1.7  No difference in complications between the groups and INR correction with FFP only delayed monitor placement and treatment

18.  Ilyas et al 2008  Earlier correction of INR with Factor VIIa verses platelet transfusion  4 units vs 7 units of plasma  Correction time was significantly improved  2.4 hours vs 10 hrs

19.  Williams et al 2008 Journal of Trauma  Elderly patients classified as 50 and older  INR >1.5 had a mortality rate of 22.6 % vs 8.2%  Suggestive of early monitoring and correction or INR in anticoagulated patients 50 and older

20. Identify and correct any specific defect of hemostasis Use non-transfusional drugs whenever possible RBC transfusion for surgical procedures or large blood loss