Expansion
Blood early, in balanced ratios, with tranexamic acid
Expansion
Definition: loss of one blood volume in 24 hours, half a blood volume in 4 hours, or ongoing loss over 150 ml per minute.
Principles
- Activate the protocol early, which mobilises the laboratory and a named coordinator
- Give blood, not crystalloid. Large volume crystalloid dilutes clotting factors and worsens acidosis
- Balanced ratios, approaching 1:1:1 of red cells, fresh frozen plasma and platelets
- Tranexamic acid 1 g within 3 hours of injury, then an infusion. It reduces mortality in trauma but increases it after 3 hours
- Permissive hypotension in penetrating trauma without head injury: aim for a palpable radial pulse
- Stop the bleeding: surgery, interventional radiology, endoscopy or obstetric measures. No amount of product substitutes for haemostasis
- Keep the patient warm, and use fluid warmers
The lethal triad: hypothermia, acidosis and coagulopathy, each worsening the others, which is why damage control resuscitation prioritises warming and product ratios over definitive surgery.
Monitor: full blood count, clotting, fibrinogen, calcium and lactate every 30 to 60 minutes, or near patient viscoelastic testing (TEG or ROTEM).
Replace calcium, since citrate in stored blood chelates it and hypocalcaemia impairs both clotting and cardiac contractility.