MASSIVE TRANSFUSION PROTOCOL- POD

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MASSIVE TRANSFUSION PROTOCOL WHEN TO INITIATE IT?

  • ABC (assessment of blood consumption) score >2- each assigned 1 point

    • Pulse >120

    • SBP <90

    • + FAST

    • penetrating torso injury

  • Shock index >1.4 (HR/sBP)

  • active bleeding requiring multiple transfusions

WHAT DOES IT CONSIST OF?

  • 1:1:1 ratio of RBC:Plasma:Platelets

TO PREP FOR BLOOD ARRIVAL

  • 2 large bore IVs

  • baseline labs- cbc, type and screen, Pt/PTT/INR, fibrinogen, BMP with magnesium

  • prepare the Belmont- rapid transfusion and warmer to prevent hypothermia

  • If trauma patient give Tranexamic acid 1gm IV over 10 minutes and then 1gm IV over 8 hours.

DURING MTP

  • Repeat labs every hour checking for electrolyte abnormalities. CORRECT THEM!

    • Hyperkalemia

    • Hypocalcemia

    • Hypomagnesemia

  • Ensure patient is not hypothermic

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Takotsubo Cardiomyopathy POD

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broken-heart.jpg

TAKOTSUBO CARDIOMYOPATHYWHAT IS IT?

  • Weakening of the left ventricle after an emotional stress

  • Aka Broken Heart

PRESENTATION

  • Classically in postmenopausal women after an emotional stress

  • Chest pain and SOB

  • ECG resembles a STEMI

  • Rapid but small rise in troponin (actual STEMI troponin takes longer to rise but has higher peak)

  • NEGATIVE angiogram

  • ECHO- ballooning of LV

HOW DID IT GET ITS NAME?

Takotsubo= a pot used to catch octopi—resembles the LV apical ballooning that occurs

takotsubo.jpg

ED MANAGEMENT: STEMI alert

** only way to differentiate from a STEMI is a negative angiogram.

PROGNOSIS: much better than STEMI.

  • Most patient’s fully recover in 2 months

  • In hospital mortality= 4%

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Targeted Temperature Management

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Targeted temperature management refers to temperature management after cardiac arrest where there was decreased or paused blood flow to the brain in an attempt to preserve neurological tissue/function. Indications

Patients not following commands or showing purposeful movements following resuscitation from cardiac arrest should have their temperature managed.

Although there are not true contraindications, here are some commonly recommended institutional indications

  • Post cardiac arrest (any cause)

  • Time < 6 hours from ROSC

  • Patient is comatose

  • MAP >=65 (with or without pressors)

Timing: As soon as possible (certainly within first couple hours) and for a duration of 48 hours.

Proposed Mechanism:

Decreasing the brain's oxygen demand (metabolic demand dec. up to 7% for every degree celcius)

Reducing the production of neurotransmitters (glutamate) and free radicals

Maintaining cell wall function

Methods:

  • Intravenous infusion of 30 mL/kgof cold (4°C [39°F]) isotonic saline, using a pressure bag to increase the rate of administration, reduces the core temperature by >2°C per hour

o   However may cause pulmonary edema (at recommended 30ml/kg)

  • Proper sedation

  • Cold water blankets

  • Ice packs (groin, axilla)

  • Ice Bath

  • Other invasive: bladder, peritoneal fluid lavage; ecmo, etc.

Target:

  • 2010 AHA guidelines recommend 32-34*C, however more recent trials show similar outcomes reducing temperature to 36*is just as effective.

o   However comparison between trials shows more fevers at the temperature target, and more fever following cardiac arrest is linked to higher mortality.

  • Per up to date 36*C for uncomplicated and 33°C for at least 24 hours when coma is deep (loss of motor response or brainstem reflexes)

Monitoring:

  • Remember minute ventilation requirements, decrease as body temperature falls and therefore a blood gas should be obtained at target temperature or every few hours (also some machines don’t correct for hypothermia – institution specific).

  • Post cardiac arrest patients should have routines labs including coagulation studies and hypoglycemia and hyperglycemia should be avoided.

  • Length of cooling is institutional specific, however most recommendations say 48 hours before rewarming.

o   Of note, over 24 hours may be linked to increase risk of infection and other adverse events.

Sources:

Bray JE, Stub D, Bloom JE, Segan L, Mitra B, Smith K, Finn J, Bernard S

Resuscitation. 2017;113:39. Epub 2017 Jan 31.

Nielsen, Niklas, et al. “Targeted temperature management at 33 C versus 36 C after cardiac arrest.”

New England Journal of Medicine 369.23 (2013): 2197-2206. PMID: 24237006; Altmetric

UpToDate

AliEM

Life In The Fast Lane

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