cristy m. thomas fnp-bc university of nevada school of medicine university medical center, las vegas...
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Cristy M. Thomas FNP-BCUniversity of Nevada School of
MedicineUniversity Medical Center, Las Vegas
NVNevada’s Only Level 1 Adult Trauma,
Level 2 Pediatric Trauma centers
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30-40 percent of trauma deaths are secondary to exsanguination
Causes of Coagulopathy in Trauma Bleeding Fluid Resuscitation Transfusions-PRBC Hypothermia Multiple injuries
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Hypothermia Acidosis Progressive Coagulopathy
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Multifactoral Dilution Consumption of Platelets Coagulation factor dysfunction of coagulation
system
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Partial thromboplastin time (PTT) Intrinsic Pathway
Prothrombin time (PT) Extrinsic Pathway
Thrombin time Common Pathway
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Fresh frozen plasmaCryoprecipitateEpsilon-amino-caproic acid (Amicar)DDAVPRecombinant human factor VIIa (Novoseven)
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SourcePlatelet concentrate (Random donor)
Each donor unit should increase platelet count ~10,000 /µlPheresis platelets (Single donor)
StorageUp to 5 days at room temperature
“Platelet trigger”Bone marrow suppressed patient (>10-20,000/µl)Bleeding/surgical patient (>50,000/µl)
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Transfusion reactionsHigher incidence than in RBC transfusionsRelated to length of storage/leukocytes/RBC mismatchBacterial contamination
Platelet transfusion refractorinessAlloimmune destruction of platelets (HLA antigens)Non-immune refractoriness
Microangiopathic hemolytic anemiaCoagulopathySplenic sequestrationFever and infectionMedications (Amphotericin, vancomycin, ATG, Interferons)
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Content - plasma (decreased factor V and VIII)Indications
Multiple coagulation deficiencies (liver disease, trauma)DICWarfarin reversalCoagulation deficiency (factor XI or VII)
Dose (225 ml/unit)10-15 ml/kg
NoteViral screened productABO compatible
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Prepared from FFPContent
Factor VIII, von Willebrand factor, fibrinogen
IndicationsFibrinogen deficiencyUremiavon Willebrand disease
Dose (1 unit = 1 bag)1-2 units/10 kg body weight
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MechanismPrevent activation plaminogen -> plasmin
Dose50mg/kg po or IV q 4 hr
UsesPrimary menorrhagiaOral bleedingBleeding in patients with thrombocytopeniaBlood loss during cardiac surgery
Side effectsGI toxicityThrombi formation
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MechanismIncreased release of VWF from endothelium
Dose0.3µg/kg IV q12 hrs150mg intranasal q12hrs
UsesMost patients with von Willebrand diseaseMild hemophilia A
Side effectsFacial flushing and headacheWater retention and hyponatremia
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MechanismActivates coagulation system through extrinsic pathway
Approved UseFactor 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
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Surgery or trauma with profuse bleedingConsider in patients with excessive bleeding without apparent surgical source and no response to other componentsDose: 50-100ug/kg for 1-2 dosesRisk of thrombotic complications not well defined
Anticoagulation therapy with bleeding20ug/kg with FFP if life or limb at risk; repeat if needed for bleeding
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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
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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
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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
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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
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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
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Identify and correct any specific defect of hemostasis
Use non-transfusional drugs whenever possible
RBC transfusion for surgical procedures or large blood loss