Trauma · 8 min
Trauma + massive transfusion — last-night quick guide
Damage control resuscitation, MTP 1:1:1, TXA window, lethal triad.
Rule
Damage control resuscitation
Permissive hypotension (SBP 80-90 OR MAP 50-60) until bleeding controlled — exception: TBI + spinal cord injury need higher MAP (>65-70). Prioritize SOURCE CONTROL > resuscitation. Minimize crystalloid (worsens dilutional coagulopathy + hypothermia + acidosis). Whole blood emerging for severe trauma.
Watch out
Lethal triad
Hypothermia + acidosis + coagulopathy reinforce each other. Keep: TEMP ≥35°C (warm blood/fluids, FAW), pH ≥7.2, INR <1.5. Active warming + warm products + Belmont rapid infuser + heat lamps + warm OR.
Rule
MTP 1:1:1
Activate: anticipated >10u PRBC/24h, >4u/hr, hemodynamic instability, ABC score ≥2 (penetrating + SBP<90 + HR>120 + +FAST). PROPPR trial (JAMA 2015): 1:1:1 vs 1:1:2 — no mortality difference but 1:1:1 had less hemorrhage death.
Rule
TXA — within 3 hours only
TXA 1g IV LOAD over 10 min + 1g over 8h infusion (CRASH-2). Must be given WITHIN 3 HOURS of injury — after 3h, TXA may HARM (CRASH-2 subgroup analysis). Exception: hemophilia + coag-specific use.
Trauma adjuncts
| Issue | Action |
|---|---|
| Hyperkalemia from old PRBCs | Calcium gluconate 1g per 4-6u; insulin 10u + D50 if severe |
| Hypocalcemia (citrate) | Calcium gluconate 1g per 4-6u |
| Acidosis | Bicarb if pH <7.1 only; treat cause (perfusion) |
| DIC + hyperfibrinolysis | Cryoprecipitate (fibrinogen <150) + TXA |
| TBI | Higher MAP (>65-70); minimize hyperventilation; head-up 30°; 3% saline |
| Pelvic fracture | Binder + IR embolization + REBOA in extreme |
Watch out
TBI specifics
EARLY intubation if GCS ≤8; AVOID hypoxia (SpO2 <95%) + hypotension (MAP <65) — even single episode worsens outcome. Normocapnia 35-40 (no prolonged hyperventilation). 3% saline preferred over mannitol modern. Propofol TIVA preferred over volatile. Head-up 30°.
Mnemonic — ABCDE
ABCDE — Primary survey, OR-adapted
ABCDE primary survey
- AAirway with c-spine — secure ETT early, neck collar maintained until imaging
- BBreathing — bilateral breath sounds, ETCO2, bilateral chest rise; tension pneumo decompression if needed
- CCirculation — large bore IVs, MTP 1:1:1, TXA <3 hr, calcium for citrate
- DDisability — GCS, pupils, glucose, narcan if indicated
- EExposure + temperature — full body inspection, prevent hypothermia (FAW + warm fluids)
In OR add: massive transfusion call early, viscoelastic testing (TEG/ROTEM), permissive hypotension until bleeding controlled.