BLOOD TRANSFUSION IN

HEMORRHAGIC SHOCK
Lasanthi Aryasinghe
PGY 3
Emergency Medicine
Rashid Hospital Trauma Center

HEMORRHAGIC
SHOCK
Most common cause is due to trauma, but it may be
caused by spontaneous hemorrhage (eg, GI
bleeding, childbirth), surgery, less commonly may be
seen in chronic conditions with subacute blood loss.
In hemorrhagic shock, blood loss exceeds the body's
ability to compensate and provide adequate tissue
perfusion and oxygenation.
Prolonged or severe splanchnic hypoperfusion can
trigger responses leading to subsequent multiple
organ failure and death.

HEMORRHAGIC
SHOCK
Coagulopathy is the failure to provide normal blood
clot formation after a trauma, injury, or tissue
disruption (hypothermia, consumption of clotting
factors. consumption of platelets, dilution of clotting
factors and platelets, trauma-induced fibrinolysis
massive blood transfusions, hypocalcemia)
Aggressive therapies with fluid resuscitation may
exacerbate this cycle by worsening the coagulopathic
processes through hemodilution.
Fluid and blood resuscitation is only a bridge for
maintaining survival and limiting morbidity until the
underlying cause can be corrected

CLINICAL
MANIFESTATIONS
Clinical appearance of the patient with acute
hemorrhage depends upon the cause, rate, volume,
and duration of bleeding, the presence of other acute
disorders; the effects of current medications; and the
patient's baseline physiologic status
Hemodynamic response:
tachycardia, hypotension, and signs of poor
peripheral perfusion (cool, pale, clammy
extremities with weak peripheral pulses and
prolonged capillary refill).
Arterial and venous vasoconstriction leads to a
narrowing of the pulse pressure.
Cerebral hypoperfusion causes alterations in
mental status.

CLINICAL
MANIFESTATIONS

Shock Index is defined as heart rate divided by

systolic blood pressure, and consistently elevates in
critically bleeding trauma patients.
A Shock Index 0.9 following injury can identify
patients with massive haemorrhage
Olaussen A, Blackburn T, Mitra B, Fitzgerald M. Review article: Shock Index for prediction of critical bleeding post trauma: A systematic review.
Emergency Medicine Australasia. 2014;1;26(3):223-8.
Pacagnella RC, et al. A systematic review of the relationship between blood loss and clinical signs. PloS one. 2013.6;8(3):e57594.

TREATMENT
Main goals of resuscitation are to stop the source of
hemorrhage and to restore circulating blood volume
Actively bleeding patients should have their
intravascular fluid replaced tissue oxygenation will
not be compromised, even at low hemoglobin
concentrations, as long as circulating volume is
maintained
No clearly defined parameters that trigger the switch
from crystalloid to blood resuscitation.
However, it is generally accepted that a patient in
shock who demonstrates minimal or only modest
hemodynamic improvement after rapid infusion of 2
to 3 L of crystalloid is in need of blood transfusion

LAB
INVESTIGATIONS
Hemoglobin concentration in an actively bleeding
individual has dubious diagnostic value - it takes time
for the various intravascular compartments to
equilibrate.
It is impossible to estimate the effect of blood
transfusion on volume or hemoglobin concentration in
actively bleeding individuals
Rather, therapy should be guided by the rate of
bleeding and changes in hemodynamic parameters
Assessing the severity and trend in base deficit and
lactate are helpful in determining the presence of
ongoing systemic hypoperfusion

LAB
INVESTIGATIONS
Antibody screen and immediate spin crossmatch at a
minimum take approximately 45 to 60 minutes
Universal (group O) blood is used when RBCs are
needed in hemorrhaging, unstable patients before
any testing can be done
Female patients receive O-negative blood to prevent
hemolytic disease of the newborn unless there is no
chance of subsequent pregnancy.
All others receive O-positive blood
Type-specific blood (with ABO and Rh testing) can
generally be made available within 15 minutes of
receiving a sample of the patients blood

TRANSFUSION
INDICATIONS
In the past, a transfusion trigger of hemoglobin (Hgb)
< 10 g/dL had been used; however, this has been
widely replaced with a lower transfusion threshold
since the Transfusion in Critical Care (TRICC) trial
results in 1999
Multicenter TRICC trial randomly assigned critically ill
patients to either a restrictive transfusion strategy (<
7 g/dL) or a liberal transfusion strategy (< 10 g/ dL)
and found decreased hospital mortality among
patients in the restrictive transfusion arm
RCT of 921 patients with acute upper gastrointestinal
bleeding (transfusion threshold < 7 g/dL or < 9 g/ dL).
Patients in the restrictive transfusion arm had a
higher probability of survival at 6 weeks, fewer
complications, and decreased bleeding when
compared to the liberal transfusion arm

TRANSFUSION
INDICATIONS
Transfusion of PRBCs is typically not indicated for
Hgb > 10 g/dL except in extraordinary circumstances,
such as massive hemorrhage.

INDICATIONS:
TRAUMA
2013 ATLS 9th edition Guidelines:
It has been emphasized that if blood pressure is
raised rapidly before the hemorrhage has been
definitely controlled, increased bleeding may
occur
The standard use of 2 liters of crystalloid
resuscitation as the starting point for all
resuscitation has been modified to initiation of 1
liter of crystalloid. Early use of blood and blood
products for patients in shock
Balancing the goal of organ perfusion with the risks of
rebleeding by accepting a lower than normal blood
pressure has been called Controlled resuscitation,
Balanced
Resuscitation,
Hypotensive
Resuscitation and Permissive Hypotension.

MASSIVE
TRANSFUSION

PROPPR RCT (>950 patients) 1:1:1 vs 1:1:2 ratio did

not result in significant differences in mortality at 24
hours or at 30 days

When giving large amounts of PRBCs, there is a

dilutional effect on platelets and coagulation factors that
will lead to coagulopathy

Replacement of > 50% of a patients blood volume

within 12- to 24-hr period or as transfusion of > 10 units
PRBCs in 24 hrs or 4 units PRBCs within 1 hour

Massive transfusions may also be required in GIB, AAA,

obstetric hemorrhage, organ transplant surgery.

Complications of MTP: hypothermia, hypocalcemia,

metabolic alkalosis, and hyperkalemia. Frequent
monitoring of temperature, pH, ionized calcium,
electrolytes, PT/INR, partial thromboplastin time, and
fibrinogen levels

MASSIVE
TRANSFUSION
Criteria to trigger the activation of an MTP should
include one or more of the following:
ABC score of two or more
Persistent hemodynamic instability
Active
bleeding
angioembolization

requiring

operation

or

Blood transfusion in the trauma bay

Assessment of Blood Consumption (ABC) score. The
ABC score consists of four variables (pulse >120,
SBP<90, + FAST, and penetrating torso injury), each
assigned one point. A score of two or more warrants
MTP activation (50% PPV, 5% NPV)

ADJUNCTS
CRASH-2 RCT >20 000 patients with major traumatic
haemorrhage showed a significant reduction in
mortality in patients receiving tranexamic acid within
3 hours of trauma with no increase in thromboembolic
events (including patients with traumatic brain injury).

Traumatic haemorrhage in adults (CRASH-2): 1 g IV within 3

hours of the event followed by 1 g infused over 8 hours.

Traumatic haemorrhage in children: 15 mL/kg (maximum

1000 mg) IV over 10 minutes followed by 2 mg/kg/h (max
125 mg/h) by IV infusion until haemorrhage is controlled.

A major international trial of tranexamic acid in 15 000

women with major postpartum haemorrhage (the
WOMAN trial) is being conducted and trials are also
in progress in gastrointestinal haemorrhage

Postpartum haemorrhage (WOMAN trial): 1 g IV followed by a

further 1g if bleeding continues or recurs.

ADJUNCTS
4 Factor Prothrombin complex concentrate (II, VII, IX
and X) for correction of warfarin-induced
coagulopathy in bleeding patients, and is
recommended over FFP for warfarin reversal in the
setting of major bleeding
Recombinant VIIa is generally not recommended for
management ofrefractory hemorrhage in trauma.

INDICATIONS:
BLEEDING
In hemodynamically stable patients,
transfusion threshold should be 7 g/dl

UGI
the

goal

Hemoglobin <7 g/dl

Continued active bleeding
Failure to improve perfusion and vital signs after
infusion of 2L NS
Ischemic Heart Disease (Hb 9-10g/dL)

2012 American College of Gastroenterology guidelines

2015 European Society of Gastrointestinal Endoscopy

INDICATIONS:
Ruptured AAA
Cross-match 6+ units of blood, consider activation of
massive transfusion protocol
Target sBP 70* to 90 mmHg to maintain end organ
perfusion
Permissive hypotension is advocated for patients with
a clinical diagnosis of rAAA to maintain an alert
patient and systolic blood pressure
2014 ESC Guidelines on the diagnosis and treatment
of aortic diseases >80 mmHg
2015 Vascular society of Great Britain and Ireland
>70 mmHg

PRACTICAL
CONSIDERATIONS
The typical volume of packedRBCs after addition of
the additive solution is 300400 mL
RBCs must be compatible with ABO antibodies
present in the recipient plasma and must be
crossmatched
Dextrose-containing solutions, if given in conjunction
with blood, can cause hemolysis and should be
avoided
PRBCs are stored for up to 42 days at 1C to 6C
During storage, several biochemical and physiologic
changes occur, including increased fragility of the cell
membrane, a decrease in 2,3-bisphosphoglycerate
and ATP levels, and an increase in potassium levels.

PRACTICAL
CONSIDERATIONS
In large-volume transfusions, if a rapid transfuser is
being used, IV 18 gauge should be used for faster
infusion rates.
NOTE:
Triple-lumen
central
catheters
and
peripherally inserted central catheter lines allow for
slower infusion rates, as they have greater resistance
due to their length and diameter
Use a rapid infuser (eg Level 1) when > 2 L of fluid or
3 units of PRBCs are required over 1 hour and when
patients are coagulopathic and/or hypothermic. The
use of rapid transfusion systems have demonstrated
a lower incidence of hypothermia, coagulopathy, and
the use of less total fluids and blood products in
resuscitation of the hypovolemic trauma patient

PRACTICAL
CONSIDERATIONS
In a stable, non-bleeding or hemolyzing adult
transfused with compatible RBCs:
Hemoglobin (Hgb) equilibrates in 15 minutes after
RBC transfusion
One unit will increase the Hgb level in an
average-sized individual by approximately 1 g/dL
and the Hct by 3%
The posttransfusion Hct can be accurately
predicted from the patients estimated blood
volume, baseline red cell volume (blood volume X
venous Hct X 0.91)

PRACTICAL
CONSIDERATIONS

TRANSFUSION
COMPLICATIONS
Annual FDA Summary FDA 2012 reported 38
transfusion-related fatalities in the United States, as
opposed to 46 in 2008 in an estimated 24 million
transfusions

COMPLICATIONS:
Mediated

Immune-

Febrile Transfusion Reaction

Most common, least serious
1 C or greater temperature elevation with transfusion
and for which no other medical explanation is found
Rx analgesics, antipyretics, and antihistamines
epinephrine and corticosteroids.

Allergic Reactions (Urticaria to Anaphylaxis)

Urticaria, or hives, during a transfusion without other
signs or symptoms and with no serious sequelae.
Allergic, antibody-mediated response to a donors
plasma proteins.
Rx transfusion does not need to be stopped, and
treatment with an antihistamine is usually sufficient

COMPLICATIONS:
Mediated

Immune-

Intravascular Hemolytic Transfusion Reaction

Most serious
Result of ABO incompatibility, most often caused by
clerical error
Onset of symptoms is immediate and include: fever,
chills, headache, nausea, vomiting, a sensation of chest
restriction, severe joint or low back pain, and a burning
sensation at the site of the infusion and feeling of
impending doom. Hypotension DIC, Acute Tubular
necrosis
Rx stop transfusion, replacing all old tubing with new,
and initiating vigorous crystalloid fluid therapy +/hemodialysis due to severe hyperkalemia from
hemolysis

COMPLICATIONS:
Mediated

Immune-

Transfusion-Related Acute Lung Injury

Leading cause of transfusion-related mortality

Rx Stop transfusion, notify blood bank, providing

respiratory support (+/- intubation ventilation). It is safe
to continue transfusion of blood products from a
different donor, if necessary. Complete resolution is
usually seen within 48 to 96 hours, mortality approx 6%

COMPLICATIONS:
Immune

Non-

Transfusion Associated Circulatory Overload

Cardiogenic pulmonary edema due to the infusion of
blood products
Rapid infusion is the most common cause of TACO, esp
in elderly patients with CHF
Rx transfusing more slowly (over a period of 4 hours @
2-4ml/min) and administering diuretics are useful in
preventing this complication

SUMMARY

Hemorrhagic shock can be rapidly fatal. The primary goal is

to stop the bleeding.

It now appears that patients who have moderate

hypotension from moderate bleeding may well benefit from
a delay in massive resuscitation, until definitive
management of underlying cause (Damage Control Resus)

Promptly initiate PRBC transfusion in patients with acute

hemorrhage or Hgb < 7 g/dL

Transfusion ratio of 1:1:1 or 1:1:2 warmed plasma,

platelets, and PRBCs when transfusing large amounts

Hemoglobin concentration should not be the only

therapeutic guide in actively bleeding patients. Therapy
should be aimed at restoring intravascular volume and
adequate hemodynamic parameters