POTD: MTP and OBH in 123

Happy Friday!

This week's Wellness POTD will be about what keeps all of us well and alive each and every day: blood! Ok so not as flashy and fun, but hopefully this is a relatively quick and dirty review of massive transfusion protocol (MTP) and OB hemorrhage (OBH) at MMC.

TLDR of MTP

• MTP is initiated if there is (1) >4 units of pRBC transfused in 1 hour OR (2) replaced all of the patient's total blood volume in 24 hours OR (3) replaced half the patient's total blood volume in 3 hours OR (4) bleeding faster than 150 ml/min

• MTP is un-crossmatched blood

• Adult MTP 1st round is 4u pRBC + 4u FFP + 1u platelets, then 2nd round is the same + 10u cryoprecipitate

• MTP is activated by an attending physician

• Notify the blood bank of MTP activation by calling 3-8400 or 3-7651

TLDR of OBH

• OBH is defined as (1) >1000 ml blood loss in any delivery OR (2) >500 ml blood loss in vaginal delivery with sxs of hypovolemia

• Call a Code H for concern for OBH

• Stage 1 think IV access/fluids/uterotonics, stage 2 think consult MFM, stage 3 think OR, stage 4 think ACLS

Ok now for the longer and more rambly (but hopefully helpful?!) details within our protocol at MMC...

Massive Transfusion Protocol

I will try to summarize the MTP protocol that Dr. Marshall shared via email, which I am also attaching to this email, and will highlight relevant facts for our clinical use in the ED.

Adult MTP Indication

1) Transfused >4 units of pRBC in 1 hour w/ more blood needed

2) Expected to transfuse >50% of a patient's total blood volume in 3 hours (most adults have around 10-12 pints/units of blood in their body)

3) Expected to transfuse >100% of a patient's total blood volume in 24 hours

4) Bleeding faster than 150 ml/min

Pediatric MTP Indication

1) Expected to transfuse >50% of a patient's total blood volume in 3 hours

2) Expected to transfuse >100% of a patient's total blood volume in 24 hours

3) Bleeding faster than 10% total blood volume/min

MTP Initiation/Termination

• Activated by an attending physician

• Initiate MTP by using the red phone by the North Side charge nurse desk or by calling blood bank at 3-8400 or 3-7651

  • Information that must be included on the call is name, MRN, sex, DOB, location, diagnosis, and contact physician info

• Have a physician fill out the "Emergency Blood Transfusion/Massive Transfusion Request" form, section B, and send it to blood bank by messenger or pneumatic tube

• Send a lavender top blood specimen for ABO antibody screening and crossmatching of continued future transfusions

• Blood bank does their magic prepping and getting us the blood...

• "Crack the fridge" in resus 51 for emergency blood to bridge us while awaiting MTP blood

  • Charge nurse has the code to the fridge

  • ED fridge contains 2 whole blood + 8 units O- pRBC + 4 units O+ pRBC + 4 units FFP (no platelets)

  • The attending physician can decide whole blood vs. components

  • Use O+ for males and O- for females

• Have the attending physician be in close contact with the blood bank to anticipate continued need

• Terminate MTP by the attending physician notifying the blood bank OR automatically terminates 4 hours after MTP started

MTP Components

MTP Tips

• Try to balance your transfusions by hour 1 or 2 into MTP (1:1:1 ratio of pRBC:FFP:platelets)

• The 1 unit of apheresis platelets in MTP is synonymous with ~6 units of individual platelets

• Use blood warmers to prevent hypothermia

• Consider TXA for trauma

• Consider calcium repletion after 3 units of transfusion

OB/Postpartum Hemorrhage

OBH Definition

1) Cumulative blood loss of >1000 ml in c-section or vaginal delivery

2) Cumulative blood loss of >500 ml in vaginal delivery with sxs of hypovolemia

OBH Stages

Stage 1: normal vital signs --> IV, fluids, fundal massage, pitocin, add other uterotonics

Stage 2: normal vital signs but blood loss up to 1500 ml OR pitocin and 2 uterotonics started --> consult MFM, transfuse, add TXA, foley, uterine balloon/packing

Stage 3: abnormal vital signs OR blood loss >1500 ml OR 2 units pRBC transfused --> go to OR, MTP

Stage 4: cardiovascular collapse --> ACLS

"Code H" aka alert the OB troops

Code H is the trigger to get more people involved for any stage OBH. It can be activated by anyone by dialing 33 and stating you have a Code H. The people notified are: OBGYN inside attending, OBGYN outside attending, anesthesia attending, anesthesia resident, chief OB resident, any individual on OB codes list, nursing leadership, blood bank.

OBH Tips 

• Consider the 4 T's of OBH when treating these patients: Tone (uterine atony), Trauma (laceration, hematoma, inversion, rupture), Tissue (retained products), Thrombin (coagulopathy)

• Use the red OB hemorrhage kit in the fridge of resus 52 which has pre-made uterotonic meds and a cheat sheet for when to use each

• Get the pitocin running early

Happy transfusing,

Kelsey

Resources:

- MMC MTP and OBH protocol

- Dr. Nicky Chung POTD from 10/8/24

- Dr. Kat Pattee POTD from 5/15/24

VOTW: Interstitial Ectopic Pregnancy

This week’s VOTW is brought to you by… none other than our fantastic ED Medical Director Dr. Nubaha Elahi and Dr. Waters!

A 44 year old female G5P3 w/ hx of Essure procedure (a 99.3% effective method of contraception) presented to the ED with bilateral eye swelling x1 week. She also had a positive home pregnancy test and vaginal spotting. Without being mislead by the initial chief complaint on a busy fast-track shift the team performed a POCUS of the pelvis which showed...

Clip 1 shows a transabdominal view of the uterus with an empty gestational sac and a thick walled complex R adnexal cyst/mass. In the setting of a bHCG of 37000, this is concerning for an ectopic pregnancy!

Clip 2 shows a transvaginal view of the uterus with an eccentrically located gestational sac containing a fetal pole. Given the concern for interstitial ectopic, the team measured the endomyometrial mantle thickness (nice!) which was 1cm (still within normal range, however approaching the 8mm cutoff).

**The Essure procedure involved inserting metal coils in bilateral fallopian tubes to cause scarring. In 2018 it was taken off of the market because it was associated with many complications including ecotpic pregnancies. 

Endomyometrial mantle thickness measurement

Interstitial ectopic

An interstitial ectopic is a pregnancy implanted in the myometrium. It carries a higher rate of shock and hemoperitoneum and higher maternal mortality compared to the other ectopic pregnancies due to the highly vascular myometrium (1)

Think about interstitial ectopic pregnancy if you see an eccentrically placed gestational sac and measure the EMM.

Endomyometrial mantle (EMM) measurement

• EMM = thickness of the endometrium + myometrium

• Measure from outer edge of the gestational sac to outer edge of the uterus at the THINNEST portion that you see (image 1)

• EMM <8mm is concerning for an interstitial ectopic pregnancy

Back to the patient

OBGYN was consulted who admitted the patient for a laparoscopic hysterectomy. The final diagnosis was right interstitial ectopic pregnancy!

We’ve reviewed many ectopic pregnancy cases caught on POCUS recently- an example of a diagnosis where POCUS truly is saving lives! Keep up the great work!

References:

1. Rastogi R, Gl M, Rastogi N, Rastogi V. Interstitial ectopic pregnancy: A rare and difficult clinicosonographic diagnosis. J Hum Reprod Sci. 2008 Jul;1(2):81-2. doi: 10.4103/0974-1208.44116. PMID: 19562051; PMCID: PMC2700669.
   

POTD: Intubating the Pregnant Patient

Intubating a pregnant woman is intimidating because you have two patients to consider. Physiologic changes in pregnancy can affect intubation so it is important to plan ahead.

Both ventilation and acid-base status change during pregnancy. As progesterone rises, there is an increase in tidal volume, which results in maternal respiratory alkalosis. This creates a gas gradient to allow for the transfer of CO2 from the fetus to the mom. This maternal hypocarbia causes uteroplacental vasoconstriction, which can cause fetal hypoperfusion and hypoxia. This creates a very delicate acid-base balance that is exacerbated by increased fetal oxygen consumption and CO2 production in the third trimester. In addition, the diaphragm is pushed up by the gravid uterus reducing the mother's functional residual capacity by 10-25%. As a result of these factors, pregnant patients have a shorter safe apnea time and can desaturate quickly.

Progesterone also decreases the tone of the lower esophageal sphincter. Combined with increased intraabdominal pressure from the gravid uterus, pregnant patients are at higher risk for aspiration. For these reasons, you should be careful with bagging and consider intubating in a semi-upright position. This position also has the benefit of taking some pressure off of the patient's chest and IVC.

Anticipate a difficult airway in pregnant patients. Failed intubation is 8x more likely than in the general population. Human placental growth hormone secreted in pregnancy increases blood flow to the upper airways. This results in edema and hyperemia of the airway, causing it to be smaller and more friable. For this reason, you should prepare a smaller caliber ETT. Rocuronium and succinylcholine have been studied with similar efficacy. Induction agents therefore depend on patient specific factors.

TLDR: 1. preoxygenate well due to shorter safe apnea time. 2. Consider a smaller ETT for a narrower and more friable airway. 3. Limit aspiration risks by decreasing bagging if possible 4. consider intubating patients in a semi-upright position.

Thanks for reading! 

Ariella

References: 

https://rebelem.com/respiratory-failure-and-airway-management-in-the-pregnant-patient/

https://www.nuemblog.com/blog/intubating-the-pregnant-patient

https://www.uptodate.com/contents/airway-management-for-the-pregnant-patient