coag values in a trauma patient

[Antrita]

We had a trauma case last week that had slightly elevated INR and PTT and a borderline normal fibrinogen. The patient had 4 packed cell units before they shipped her out. I thought she should have had FFP or at least a repeat coag tests, which she did not. Her results weren't that bad but in a trauma I thought it was a bad sign. The trauma RN said they MD is to busy working on the patient to check the coag results. Great response. Do any of you have trigger values that would require either repeat coag tests or automatic FFP when dealing with trauma patients?

Antrita

[David Saikin]

The only "automatic" orders we have are for massive transfusion . . . your patient would not qualify for the start of that protocol. I wouldn't be concerned with those results.

[Likewine99]

Like David we have a Massive Transfusion protocol that the BB follows to help guide the docs in the ED since they are so busy.

With only slightly elevated results, at our place, this pt wouldn't have qualified for FFP. We do Coag tests after 6 units of PC.

In the future you could always "ask" if there are any labs they might need. As a courtesy to the ED and as a service to the pt.

[Deny Morlino]

Cultivate a good working relationship with your ER chief if possible. Most of our ER docs follow his lead and are willing to discuss testing of this sort if we recommend it as they frequently have other things on their mind in these situations. On many occasions a tech has asked a polite question with a hint of a recommendation and the doctors are usually receptive to the input. As the volume of tests available increases and the amount of knowledge docs must try to keep track of grows they are often more receptive to input from the folks that "work with" the tests every day. Teamwork rah, rah, rah!

[tbostock]

Actually early transfusion of plasma in trauma patients has been shown to be very beneficial in preventing the "lethal triad" of mortality in trauma. The INR is the lab result that is one of the best predictors of mortality in a trauma patient. An INR greater than 1.5 indicates that coagulopathy has already begun, and quick administration of plasma has been shown to produce better outcomes. So if you wait until the patient is already diluted with too many units of red cells, or (even worse) wait until the physician realizes that FFP is needed, you're already playing catch-up. Your massive transfusion protocol should include a protocol for FFP transfusion if the patient's initial INR on admission is elevated.

From http://bja.oxfordjournals.org/content/95/2/130.full, and several other articles about coagulopathy in trauma:

Coagulopathy occurs early in the post-injury period,61 and has been shown to be an independent predictor of mortality.55,60,61 Therefore, correction of coagulopathy may potentially decrease mortality in patients with severe trauma.

[tbostock]

Actually early transfusion of plasma in trauma patients has been shown to be very beneficial in preventing the "lethal triad" of mortality in trauma. The INR is the lab result that is one of the best predictors of mortality in a trauma patient. An INR greater than 1.5 indicates that coagulopathy has already begun, and quick administration of plasma has been shown to produce better outcomes.

From http://bja.oxfordjournals.org/content/95/2/130.full, and several other articles about coagulopathy in trauma:

Coagulopathy occurs early in the post-injury period,61 and has been shown to be an independent predictor of mortality.55,60,61 Therefore, correction of coagulopathy may potentially decrease mortality in patients with severe trauma.

[Antrita]

My concern with this patient was, she was here for 1 hour before she started to bleed. They gave her 4 units of packed cells and then shipped her out with 2 more units in the ambulance. Her coag tests were never repeated. If slightly abnormal INR and PTT were the start of a coagulopathy from trauma, giving her 4 units of blood with out FFP wasn't going to improve the situation. We have a massive trauma protocol which includes FFP with every 4 units but the ER doc did not call for the protocol. I think we are going to start issuing FFP along with orders for uncrossmatched blood. This patient did not survive.

I think at our facility we are quick to look at the trauma patient's hemoglobin when they get here. We have always looked to the MD to order the right products. The massive transfusion protocol was established to help this process along but when they don't make that call we are in limbo.

[Antrita]

Someone from another hospital told me they have a code for "bloody" traumas called Code Crimsom. When they get a code Crimsom they send 3 units of O neg packed cells and 1 Jumbo FFP to the ER. This is separate from a regular code Trauma and a Massive Transfusion Protocol. Does anyone else do something like this? It seems like this would take the burden off the blood bank.

[momie]

My concern with this patient was, she was here for 1 hour before she started to bleed. They gave her 4 units of packed cells and then shipped her out with 2 more units in the ambulance. Her coag tests were never repeated. If slightly abnormal INR and PTT were the start of a coagulopathy from trauma, giving her 4 units of blood with out FFP wasn't going to improve the situation. We have a massive trauma protocol which includes FFP with every 4 units but the ER doc did not call for the protocol. I think we are going to start issuing FFP along with orders for uncrossmatched blood. This patient did not survive.

I think at our facility we are quick to look at the trauma patient's hemoglobin when they get here. We have always looked to the MD to order the right products. The massive transfusion protocol was established to help this process along but when they don't make that call we are in limbo.

so it means, just coz of the ER doc mistake that patint did not survive............thats really sad...

[SMILLER]

Like many others here, we have a Massive Transfusion Protocol that includes sending FFP automatically at a certian point based on the INR. 2 u if >1.5, 4 u if > 3.0, etc.

For regular traumas, we send 4 O negs when requested to ER. We would rely on the ER doc or OR to keep track of the Lab values.

It does seem alarming that a bleeding patient would be shipped out without attention paid to the coag results, if that was the case.