Description
Massive Transfusion Protocol (MTP) is a standardized medical procedure activated in cases of severe hemorrhage, typically involving the rapid administration of large volumes of blood products. The goal is to restore circulating volume, maintain hemostasis, and prevent the lethal triad of hypothermia, acidosis, and coagulopathy. MTP usually involves a balanced ratio of packed red blood cells, plasma, and platelets, often in a 1:1:1 ratio. Early activation and coordination among trauma teams, laboratory services, and blood banks are essential for its success.
Summary Listen
- The speaker addresses the complexities of implementing massive transfusion protocols (MTP), particularly in resource-constrained government settings. They highlight the challenges not only in medical decision-making but also in logistics, and how they've achieved 80% success in addressing these issues through a pragmatic approach. They aim to avoid a data-heavy presentation, focusing instead on practical applications.
- The lecture focuses on the importance of addressing the neglected areas of MTP: "how to do it," "what to do," execution, technical details, logistics, and readiness. The initial challenge is knowing when to initiate the protocol and how many blood products to administer. The emphasis is on appropriate product selection to enhance overall efficacy, and recognizing that transfusion is merely stabilization, not a cure.
- The speaker underscores the need for flawless execution across all teams (doctors, nurses, lab staff, etc.) and robust logistics, including transport, communication channels (e.g., NEWS protocol, ISBAR), and pre-approved forms. They stress that consistent readiness encompassing all aspects of the protocol is critical for success.
- Referencing 2021 data from a developed nation to highlight potential issues in less developed contexts, the speaker emphasizes the importance of minimizing blood product waste. They propose a pragmatic definition of MTP: requiring greater than 50% blood volume loss in 4 hours, or more practically, needing >=4 packed red blood cells in 4 hours. Early recognition and maintenance of tissue perfusion are crucial.
- The speaker advocates for the ABC score (penetrating injury, systolic blood pressure, heart rate, FAST exam) as a rapid assessment tool. A score of 2 or more suggests a higher likelihood of needing massive transfusions. The traditionally followed 1:1:1 ratio (packed red blood cells:FFP:platelets) is emphasized, acknowledging that variations (e.g., 1:1:2) might be required in specific cases like gynecological shock.
- The lecture also highlights the importance of adjunctive therapies, including fibrinogen replacement when indicated, tranexemic acid (TXA) within 3-8 hours of the injury (with caution after 8 hours), and reversal agents for anticoagulants (e.g., prothrombin complex concentrate for factor Xa inhibitors or warfarin). Calcium chloride or gluconate is also mentioned to address calcium deficits caused by transfusion.
- Frequent monitoring is vital in MTP, including temperature (target 36-37°C), acid-base status, calcium levels, hemoglobin (target 7-8 g/dL, unless specific conditions require higher levels), platelet count (>50,000/µL, closer to 100,000/µL in intracranial hemorrhage), and INR/aPTT (<1.5 times normal). Thromboelastography (TEG) is strongly recommended to assess platelet function.
- The speaker presents a simplified, chart-based MTP protocol used in their hospital. This protocol involves two scores the ABC and the TASH score and is focused on rapid activation using pre-prepared kits with forms, blood collection bottles, and a lab requisition. The initial focus is the delivery of a pre-determined package of blood products within 45 minutes, non-cross matched or o positive when indicated, while securing IV access.
- After the initial package of blood products is delivered, a reassessment point takes place around the four hour mark that includes repeating the ABC and TASH scores as well as drawing repeat labs (e.g., CBC, CMP, coagulation) to check on homeostasis. After this point another determination is made to determine if the patient is stable enough to come off MTP with both the ABC and TASH scores below a set point as well as hemodynamic stability.
- The lecture concludes by underscoring the importance of a plan ready to be implemented and addressing contingencies. The speaker stresses that non-availability of matched products should not delay transition. Finally, the speaker concludes with a call to action to be cautious with blood product administration.
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