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

POTD: To intubate or not?

Happy Thursday!

Today, we will be discussing an interesting ethical topic that is based on a patient that presented to the ED a few months ago. To set the scene, imagine you are working resus and you get a notification by EMS that there is an unresponsive patient coming in who is currently being bagged. Upon arrival, EMS informs you that they were found on the floor of their home surrounded by multiple pill bottles that contain opioids and benzos. As you get ready to intubate, you find out this patient has a DNI/DNR order. What do you do in this situation if you are concern this was a possible suicidal attempt? Do you honor the DNI/DNR that the patient made while they had capacity or do you disregard it because this patient had a possible suicide attempt? Lets dive deep into this discussion. 

Lets start with DNR/DNI, when you decide to make yourself DNR/DNI, DNI or DNR, at that time you have been determined to have medical capacity and able to make an informed decision about your medical care. First point, a MOLST form is different from a DNR/DNI order. A Medical-Orders for Life Sustaining Treatment (MOLST) form can only be filled out by physician, NP or PA and is intended for patients with serious health conditions who want to avoid/ receive any or all life-sustaining treatment, reside in a long-term care facility or require long-term care services and /or might die within the next year. A DNI or DNR is a medical order written by a healthcare provider stating either do-not intubate, do-not-resuscitate, or both. Under NY state law, the MOLST form is the only authorized form in New York State for documenting both non-hospital DNR and Do Not Intubate (DNI) orders. 

In New York, a DNR order only refers to withholding CPR during respiratory or cardiac arrest; it does not make any determinations on other medical treatments or the withdrawal of medical care. What do you do in the setting of suicide as the emergency medicine physician when you may have limited time and information when this type of patient comes to your ER? 

When researching this, it seems to be split 50/50. Some physicians believe that regardless of how if a patient has a DNI/DNR then they will respect it even in the setting of suicide while other physicians believe that suicide may have a possible reversible cause / good outcome. When I asked some of our ED attendings, there were some split points of views, one said each scenario would be different but it would be important to involve our ethics committee because each situation may not be so clear-cut. 

Something to note is that immunity for physicians who disregard a DNR is provided in situations where, in good faith, the physician had reason to believe the DNR was revoked or canceled, or they were unaware of the DNR, there is not a clear answer when it comes to a suicidal patient. 

When reviewing some case reports written about DNR/DNI in a suicidal patients, both courses of actions have been taken: upholding the order and disregarding it. There is no legal precedent on what to do in this situation. One case reported involved a middle aged female with a medical history of Major depressive disorder who was found unresponsive during this inpatient psych admission after presumed opioid overdose, at that time she was found holding her DNR document, in this situation the medical team and on-call psychiatrist decided to resuscitate the patient. This case was referred to the ethical board and they agreed with the psychiatrist decision of suspending that patient’s DNR during that situation because suicide represents disordered thinking and the patient had no capacity to make medical decisions and the patient had no life-threatening or terminal illnesses. There are other cases where an ethics committee has decided that the DNR order should be upheld. Many institutions don’t have set guidelines in place regarding overriding DNR /DNI orders in the context of a suicide attempt. 

One of the first things we may think about when overriding a DNR is the legality of it. If we disregard it then technically we are going against a patient’s autonomy since when they made their DNR/DNI they had medical capacity… but then does the patient have medical decision-making capacity and autonomy at the time of a suicide attempt?

Key Takeaways for Decision-Making in DNR/DNI Situations with Suspected Suicide Attempts:

1. Start with the Basics: Verify the validity of the DNR/DNI or MOLST form. Understand what treatments it explicitly prohibits and what it permits.

2. Assess Capacity: Suicide attempts often suggest temporary mental incapacity, which may invalidate prior autonomous decisions.

3. Err on the Side of Life: When in doubt, prioritize interventions that preserve life, especially if the situation seems reversible (possibly the most controversial point but do what you believe is right for your patient, like I said, each situation is unique) 

   1. If you are truly unsure on what to do, you may err on the side of life 

   2. Take note, that some physicians will honor the DNR/DNI or MOLST form regardless of the situation, make sure to document your actions/ reasoning well

4. Consult and Collaborate: If time permits, involve ethics, psychiatry, and legal teams to guide complex decisions.

5. Document Thoroughly: Always clearly document your reasoning and actions, particularly if you decide to override a DNR/DNI order. Good faith actions are legally protected in NY State.

6. No Perfect Answers: Acknowledge that every case is unique and requires individualized clinical, ethical, and legal considerations.

I hope you made it til the end of this long POTD. 

Resources:

https://pmc.ncbi.nlm.nih.gov/articles/PMC7805523/

https://www.researchgate.net/publication/309214885_Suicidal_Patients_with_a_Do-Not-Resuscitate_Order#:~:text=Background%3A%20A%20suicidal%20person%20with,setting%20of%20a%20suicide%20attempt.

https://blog.clinicalmonster.com/2022/09/22/dnr-orders-in-the-suicidal-patient/

chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.corpuspublishers.com/assets/articles/crpbs-v4-23-10102.pdf 

https://www.cambridge.org/core/journals/bjpsych-open/article/advance-decisions-to-refuse-treatment-and-suicidal-behaviour-in-emergency-care-its-very-much-a-step-into-the-unknown/3365ABDAD49526E22073A5B8F801CD6F

Thanks everyone, 

Caroline Paz

Sep-tacular Views of Ascites

HPI: This is a 72-year-old male with a PMH of cirrhosis and multiple other medical comorbidities who presented from his nursing home with vomiting and abdominal pain and distention.

POCUS revealed loculated ascites, which was confirmed on CT abdomen.

The patient underwent diagnostic paracentesis under dynamic ultrasound guidance, which yielded 50mL of serosanguinous fluid.

Ascites on Ultrasound

• Ultrasound is a useful tool for diagnosing ascites because it can detect small amounts of abdominal free fluid not otherwise felt on physical exam and help estimate volume

• It can guide safe paracentesis by helping visualize bowel and other organs to avoid

• Simple ascites appears anechoic while hemorrhagic or exudative ascites will often contain floating debris

• Septations (aka loculations) suggest an inflammatory or neoplastic cause
  

Clip 1 shows complex abdominal free fluid with loops of bowel floating within it.

Clip 2 shows an ultrasound-guided paracentesis. Note the needle being introduced into the ascitic fluid from the right side of the screen. The linear probe is used for better resolution of the superficial structures. Color flow can be used to identify the inferior epigastric artery and other vasculature to avoid puncturing in the abdominal wall.

This Core Ultrasound video gives a helpful rundown on how to perform an ultrasound-guided paracentesis.

Case conclusion: Spontaneous bacterial peritonitis was diagnosed based on the ascitic fluid containing >8000 neutrophils, and antibiotics were initiated. The patient was admitted. His hospital course was complicated by acute renal failure and an acute duodenal ulcer bleed, and he remains admitted 1 month later.

References:

• https://radiopaedia.org/articles/ascites?lang=us

• https://www.thelandofem.com/blog/2022/7/8/iusotm-ascites-evaluation-and-management