Ep 152 The 7 Ts of Massive Hemorrhage Protocols

What’s in the name – why “Massive Hemorrhage Protocol” and not “Massive Transfusion Protocol”? In this episode - The 7 Ts of Massive Hemorrhage Protocols, Dr. Jeannie Callum, Dr. Andrew Petrosoniak and Dr. Barbara Haas join Anton in answering the questions: How do you decide when to activate the MHP? How do you know when it is safe to terminate the MHP? What lab tests need to be done, how often, and how should the results be shared with the clinical team? Once the dust settles, what do we need to tell the patient and/or their family about the consequences of being massively transfused? What should be the lab resuscitation targets? Why is serum calcium important to draw in the ED for the patient who is exsanguinating? How do we mitigate the risk of hypothermia? What can hospitals do to mitigate blood wastage? If someone is on anti-platelets or anticoagulants what is the best strategy to ensure the docs in the ED know what to give and how much? Until the results of lab testing come back and hemorrhage pace is slowed, what ratio of plasma to RBCs should we target? What's better, 1:1:1 or 2:1:1? Should we ever consider using Recombinant Factor 7a? If the fibrinogen is low, what is the optimal product and threshold for replacement? When and how much TXA? Anyone you wouldn’t give it to? and many more... Podcast production, sound design & editing by Anton Helman; Written Summary and blog post by Saswata Deb & Priyank Bhatnagar, edited by Anton Helman; Infographic by Pouria Rezapour, edited by Anton Helman, February, 2021 Cite this podcast as: Helman, A. Callum, J. Haas, B. Petrosoniak, A. The 7 Ts of Massive Hemorrhage Protocols. Emergency Medicine Cases. February, 2021. https://emergencymedicinecases.com/7-ts-massive-hemorrhage-protocols. Accessed [date] When a patient is exsanguinating, having a standardized massive hemorrhage protocol (MHP) enables rapid and coordinated delivery of life-saving blood products, medications. Every one-minute delay in receiving the first pack red blood cells (pRBC) in a bleeding trauma patient is associated with a 5% increase in mortality. Why Massive Hemorrhage Protocol instead of Massive Transfusion Protocol? The classic definition of massive transfusion protocol is 10 units of pRBC over 24 hours and only focuses on the number of blood products transfused. Instead, the emphasis should be placed on hemorrhage control which not only includes transfusions, but also monitoring blood work/considering targets, administration of other medications including tranexamic acid, keeping the patient warm and source control of the bleeding. The 7 Ts of Massive Hemorrhage Protocols: Trigger, Team, Testing, TXA, Temperature, Target, Termination Trigger: indications for MHP prehospital, at initial ED assessment and during resuscitation The decision to active a MHP should be guided by clinical judgement, decision tools and response to treatment. A) Prehospital indications for MHP include a concerning mechanism of injury (eg., fall from ≥ 3 stories) and/or a shock index ≥ 1. B) Initial ED assessment indications for MHP include clinical judgement incorporating clinical decision tools, resuscitation intensity and pitfall conditions. * Clinical judgement (obvious shock state or else incorporating shock index >1, delta shock index ≥0.1, RABT Score ≥2, AND