Aug. 12, 2021
Many traumatic events may prompt the need for hemostatic resuscitation. According to James R. Stubbs, M.D., the chair of Transfusion Medicine at Mayo Clinic's campus in Rochester, Minnesota, some of the most common events include blunt force trauma, such as from motor vehicle collisions, or severe falls, such as falling off the roof of a building.
The nature of these types of injuries may lead to blood loss and blood-clotting issues. For people who are severely injured, professionals need to provide support to maintain perfusion.
Hemorrhagic shock remains the most common indication for hemostatic resuscitation, along with instances where providers see a patient is moving toward shock and want to prevent hypotension.
Though trauma as a medical field often studies hemostatic resuscitation and thus its practice is highly data driven, the methods apply for any kind of hemorrhage, says Martin D. Zielinski, M.D., a trauma surgeon at Mayo Clinic in Minnesota.
Goals of hemostatic resuscitation
When performing hemostatic resuscitation, the key goals for the patient are:
- Controlling hemorrhage
- Maintaining adequate perfusion
- Preventing coagulopathy, acidosis and hypothermia
Dr. Zielinski indicates goals 2 and 3 involve balanced blood product resuscitation; goal 1 is the priority and is completed by a surgeon.
Evolution from heavy crystalloid use to damage control resuscitation
Hemostatic resuscitation today differs from methods used previously. Now, the preferred method involves starting with transfusion therapy early in treatment to provide volume support, plasma and platelets, and support for hemostasis.
"The old method was if the patient required blood volume replacement, you gave clear fluids — large volumes of normal saline or lactated Ringer's solution," says Dr. Stubbs. "If the patient did not respond satisfactorily to volume replacement with clear fluids, red cell transfusions would be added to the resuscitation effort to augment blood volume replacement and improve oxygen-carrying capacity."
Studies found that large crystalloid volumes were detrimental to patients and led to volume overload, according to Dr. Stubbs. Negative outcomes include dilutional coagulopathy, acidosis, hypothermia and abdominal compartment syndrome.
"They were just volume replacement, not treatment of hemorrhagic shock features," says Dr. Zielinski. "Perfusion is maintained, but oxygenation is not."
Today's method, called damage control resuscitation (DCR), involves early aggregate replacement of red cell mass and hemostasis, red blood cells, plasma and platelets, or whole blood, which Dr. Stubbs notes may be easier to administer in a prehospital environment.
Another key aspect of DCR is tourniquet control, says Dr. Zielinski, including local pressure on an extremity or operative control on a truncal wound.
However, DCR may involve challenges in accessing needed products, especially platelets, which only store for five days. "It's hard to maintain a local platelet supply," says Dr. Stubbs. "This has been an issue for small hospitals that provide trauma care." He proposes two options to address the supply issue:
- Maintain a whole blood supply, which lasts 35 days
- Refrigerate platelets, extending use to 14 days
Dr. Stubbs says there's a movement toward the refrigeration strategy, and experts in transfusion medicine are trying to convince the Food and Drug Administration (FDA) of its efficacy and benefits. He says that the South Texas Blood & Tissue Center successfully argued that because of the critical access hospitals they support, the center needed cold-stored platelets. This center received a special license from the FDA to manufacture cold platelets where standard platelets aren't available.
Dr. Stubbs advocates that small hospitals nationwide consider this process to provide platelets for trauma patients with severe injuries. The FDA issued Mayo Clinic's campus in Rochester, Minnesota, a variance to store refrigerated platelets for 14 days. Not only does this extend use of the platelets, but because prehospitalists can store platelets in a cooler, staff can keep platelets with red blood cells and plasma in ambulances, allowing for remote DCR.
Best options for small hospitals to prepare for DCR
Dr. Stubbs suggests that small hospitals stock the following items to be ready for patients needing DCR: Group O red blood cells and group AB plasma — the universal red blood cell and plasma blood components. However, group AB plasma is difficult to stock in large amounts because it is the rarest ABO blood type in the population. As an alternative to group AB plasma, group A plasma has been shown to be a safe and more readily available option for DCR.
Dr. Stubbs also recommends that facilities encourage their blood suppliers to request an FDA variance for cold-stored platelets. Another option is low-titer group O cold-stored whole blood, which is approved as a universal donor blood product.
Dr. Zielinski also recognizes that not every facility carries all blood products. He encourages trauma professionals to replace blood with the closest available product on hand. He also suggests using the services of blood product delivery companies for severe trauma, some of which use drones.
In addition, if first responders transport a patient in a Mayo Clinic helicopter, the helicopter will be stocked with group O whole blood, packed red blood cells and plasma, all of which are provided by only a minority of air ambulance services in the U.S., says Dr. Zielinski. Mayo Clinic's air ambulances were carrying all these blood products before any other medical helicopter service in the nation.
It's ideal to give plasma and platelets simultaneously in an all-in-one resuscitative product, group O low-titer whole blood, which hospitals may stock up to 35 days, preventing waste. Dr. Stubbs recommends that maintaining active and timely communication with blood suppliers can help decrease time lags for the delivery of critically needed blood products.
Hemostatic adjuncts
It's also important to consider massive hemorrhage control adjuncts, other methods and products useful for hemostatic resuscitation. First, employ thromboelastography, if available, to determine the patient's coagulation status. Some options for supplemental therapy include:
Antifibrinolytic agents
These agents are especially important in patients with major bleeding because they inhibit clots from rapidly dissolving.
Prothrombin complex concentrate
This contains a mixture of clotting factors (factors 2, 7, 9 and 10 — sometimes also called clotting factors II, VII, IX, and X) that can be used to rapidly reverse the anticoagulant effects of warfarin and for the treatment of bleeding associated with deficiencies of these factors.
Fibrinogen concentrate
This is a protein naturally found in plasma that can help replace fibrinogen, which is critical to achieve adequate formation of fibrin clots. Hospitals may store this product longer than other blood products; however, its disadvantage is that it requires reconstitution, which takes 5 to 20 minutes.
Direct thrombin reversal agents
Though expensive, trauma personnel may use these agents in a life-threatening situation.
Blood warmers
These raise the temperature of fluids administered, helping prevent hypothermia. Active rewarming also is an option if a patient does become hypothermic, in addition to warming the room.
Meanwhile, platelets remain central to DCR, and investigators continue to seek ways to make them rapidly available to patients with severe injuries.
Cautions for hemostatic resuscitation
Dr. Zielinski shares one word of caution about hemostatic resuscitation: Watch that you don't over-transfuse the patient. He says blood resuscitation can be a double-edged sword.
"You are saving the patient's life, but over-transfusion of blood products leads to mortality," he says. "In other words, you must provide the correct amount of blood products to maintain the tenets of hemostatic resuscitation while recognizing that blood products have potential complications."
Blood product microparticles may contribute to microthrombosis; they also may lead to end-organ damage or temporary immunosuppression.
Dr. Zielinski urges trauma professionals to make sure any blood products they are giving are appropriate for the patient, and to know the hemoglobin, hemostatic and volume status of the patient before beginning DCR. He recommends, "Do the best you can with what you have available and call for the helicopter to transport the patient and take them to a Level 1, or Level 2, Trauma Center, which stocks a wide array of blood products."