1 00:00:00,000 --> 00:00:05,000 Global Cast MD, along with Cincinnati Children's Hospital, 2 00:00:05,000 --> 00:00:08,000 sharing knowledge to improve child health around the globe. 3 00:00:08,000 --> 00:00:15,000 Hello, Pediatric Surgery family. 4 00:00:15,000 --> 00:00:20,000 I'm Amgodi, a research fellow from Cincinnati Children's Hospital Medical Center. 5 00:00:20,000 --> 00:00:25,000 Our 11th annual update course in pediatric surgery was held past August. 6 00:00:25,000 --> 00:00:29,000 In this video series, we'll recap the sessions and share the main highlights with you. 7 00:00:29,000 --> 00:00:40,000 In this video, Drs. Meera Kodakal and Katie Russell are sharing their guidelines and the updates in massive transfusion protocols, or MTPs. 8 00:00:40,000 --> 00:00:42,000 Alright guys, here's our next scenario. 9 00:00:42,000 --> 00:00:46,000 So this is an eight-year-old who's got a gunshot wound to the abdomen. 10 00:00:46,000 --> 00:00:50,000 He was playing with his four-year-old brother and he was unintentionally shot. 11 00:00:50,000 --> 00:00:58,000 He is hypotensive, despite already getting the bolus of chrysaloid in the field, and he's now got in 20 milliliters per kilo of blood. 12 00:00:58,000 --> 00:01:03,000 Our question is, when should we activate a massive transfusion protocol? 13 00:01:03,000 --> 00:01:07,000 And you've got the cooler in front of you. Now, what product are you going to give first? 14 00:01:07,000 --> 00:01:11,000 So we would often get to 40 per kilo of blood and then go to a one-to-one-to-one. 15 00:01:11,000 --> 00:01:15,000 So I don't have great data for this, but I actually start with FFP. 16 00:01:15,000 --> 00:01:18,000 I think there is adult data to support that. 17 00:01:18,000 --> 00:01:23,000 Yeah, absolutely. The data on one-to-one-to-one resuscitation I think is really important. 18 00:01:23,000 --> 00:01:28,000 We do have plasma in our original trauma cooler that comes to the bay, and then we get more. 19 00:01:28,000 --> 00:01:33,000 Dr. Kodagal also mentioned that they don't have platelets in their original trauma cooler. 20 00:01:33,000 --> 00:01:38,000 So in order to get platelets, they have to activate MTP or order platelets separately. 21 00:01:38,000 --> 00:01:44,000 I don't know the answer of when is the time. I don't know if it's the same everywhere for when you call. 22 00:01:44,000 --> 00:01:48,000 I would always do it just because of gestalt. I'd be like, okay, I gave blood, I'm going to call MTP. 23 00:01:48,000 --> 00:01:53,000 I think that's actually the take-home point. So we're going to show some new studies. 24 00:01:53,000 --> 00:01:58,000 But if you're in the trauma bay and you're giving blood, you need to activate it. 25 00:01:58,000 --> 00:02:03,000 Blood equals MTP. That's its phrase to remember. If you give blood, call MTP. 26 00:02:03,000 --> 00:02:06,000 Is that standard or is that your opinion at your hospital? 27 00:02:06,000 --> 00:02:11,000 This is actually a new paper. There are these blood investigators. They're part of the MADC trial, 28 00:02:11,000 --> 00:02:14,000 looking at whole blood versus component therapy. 29 00:02:14,000 --> 00:02:18,000 But they wrote a bunch of papers out of the first iteration of this trial. 30 00:02:18,000 --> 00:02:24,000 And after 20 per kilo of blood, within an hour, you should activate the MTP. 31 00:02:24,000 --> 00:02:30,000 And what gets destroyed or ruined when you call an MTP and don't use it? 32 00:02:30,000 --> 00:02:32,000 Its resources. 33 00:02:32,000 --> 00:02:33,000 What about blood? 34 00:02:33,000 --> 00:02:37,000 So usually no. Unless you spike the bag, the blood can be returned to the blood. 35 00:02:37,000 --> 00:02:41,000 When do you give something other than packed red blood cells? And what do you give? 36 00:02:41,000 --> 00:02:46,000 Bad trauma coming in. Not normal at all. Whole blood would be the best, I think, personally. 37 00:02:46,000 --> 00:02:50,000 So we have not been able to get our blood bank to make whole blood for kids because it needs to be open. 38 00:02:50,000 --> 00:02:56,000 We want to aim for one-to-one-to-one, for sure. And definitely FFP should be what you give after you give blood. 39 00:02:56,000 --> 00:03:01,000 Most of the time, an original trauma cooler that comes to the bay in most hospitals does not have platelets. 40 00:03:01,000 --> 00:03:03,000 The MTP helps you get platelets or you can call for platelets. 41 00:03:03,000 --> 00:03:07,000 This paper basically is the definition for an MTP. 42 00:03:07,000 --> 00:03:11,000 People have different definitions for what massive transfusion kids actually is. 43 00:03:11,000 --> 00:03:17,000 But I think the best one is 40 of any blood product over 24 hours. 44 00:03:17,000 --> 00:03:18,000 So do you agree with that? 45 00:03:18,000 --> 00:03:25,000 I would. And I think it's worth clarifying that activating your MTP and your threshold for doing that is different than massive transfusion. 46 00:03:25,000 --> 00:03:35,000 According to this paper, any time you give kids 40 milliliters per kilo or more blood, you should consider it as a massive transfusion. 47 00:03:35,000 --> 00:03:40,000 When you decide to activate your massive transfusion protocol, which is going to bring you lots of blood, is a different question. 48 00:03:40,000 --> 00:03:45,000 Yeah. Next paper. This is the paper about one-to-one-to-one, right? 49 00:03:45,000 --> 00:03:48,000 And in this paper, they looked at a balanced resuscitation. 50 00:03:48,000 --> 00:03:54,000 The main idea is the more fresh frozen plasma or FFP you give, the lower your mortality is. 51 00:03:54,000 --> 00:04:00,000 The closer you are one-to-one-to-one is better. And these guys have shown this in kids. 52 00:04:00,000 --> 00:04:04,000 So it's not just adult data at this point. And I think there's great pediatric data on whole blood. 53 00:04:04,000 --> 00:04:09,000 So in the event that you can't, balance resuscitation is really important because kids bleed whole blood. 54 00:04:09,000 --> 00:04:15,000 And then last paper. So this is you're in the trauma bay. You are actively transfusing. 55 00:04:15,000 --> 00:04:21,000 They've gotten 20 per kilo and they're still not stable. So this is new data. Our protocol is next. 56 00:04:21,000 --> 00:04:25,000 We're doing 40 as of now, but I think that it's certainly an area for improvement. 57 00:04:25,000 --> 00:04:32,000 This is a low frequency, high-acuity event. And every now and then there will be a GI bleeding or a bad liver transplant. 58 00:04:32,000 --> 00:04:35,000 So sometimes it is just useful to have a second set of heads. 59 00:04:35,000 --> 00:04:42,000 We recently created an MTP team that responds anywhere in the hospital to try to help run these resuscitations. 60 00:04:42,000 --> 00:04:44,000 And so all they're in charge of is giving the blood. 61 00:04:44,000 --> 00:04:49,000 Primary physicians can take care of dealing with what the underlying medical problem is. 62 00:04:49,000 --> 00:04:51,000 And then we just go and give blood. Who's on your team? 63 00:04:51,000 --> 00:04:57,000 The trauma APP is running the team. And then we bring an ER nurse who knows how to run the Belmont. 64 00:04:57,000 --> 00:04:59,000 That's like the core team. 65 00:04:59,000 --> 00:05:04,000 And they go with the blood to the bedside, give the blood and they say, we've got to get the labs and check back in. 66 00:05:04,000 --> 00:05:11,000 What we showed is that we changed our balance resuscitations. Our balance resuscitation used to be 25 percent. 67 00:05:11,000 --> 00:05:17,000 And then after activating this team, we're now up to 85 percent on our balance resuscitation. 68 00:05:17,000 --> 00:05:24,000 Do you do pre-hospital transfusion? We recently did a visual abstract about this and I don't have it available in Chile, 69 00:05:24,000 --> 00:05:28,000 but I'm guessing if you do, it could even reduce mortality. 70 00:05:28,000 --> 00:05:34,000 The data definitely supports that. We will have patients who may get blood started in an outside hospital, but our EMS does not. 71 00:05:34,000 --> 00:05:40,000 And Dr. Kadegal shares her experience from a hospital that they partnered with in the Netherlands. 72 00:05:40,000 --> 00:05:45,000 Their trauma program and they have an incredibly cool system. They have a helicopter based team. 73 00:05:45,000 --> 00:05:50,000 They actually rendezvous in the field, so they ECMO cannulate in the middle of a tulip field. 74 00:05:50,000 --> 00:05:54,000 And they will take their team to meet the patient in the ambulance and then transport. 75 00:05:54,000 --> 00:06:00,000 So that they're actually starting their resuscitation in the field with an anesthesiologist and a nursing support. 76 00:06:00,000 --> 00:06:05,000 Blows my mind they actually cannulate. Like if they need to for ECMO kits, they cannulate in the field, which is incredible. 77 00:06:05,000 --> 00:06:13,000 Can you comment on pre-hospital TXA? Yeah, we are not routinely doing it, but I think there is evidence to support its use. 78 00:06:13,000 --> 00:06:20,000 I do encourage them for people that are using TXA and MTP to get a rotam or a Teg as fast as you can, 79 00:06:20,000 --> 00:06:24,000 because there's going to be a delay a little bit. If you have rapid Teg, it's great. 80 00:06:24,000 --> 00:06:30,000 But if it's a rotam, it takes a little longer. But as soon as you can directly target your goals for resuscitation, 81 00:06:30,000 --> 00:06:35,000 it will highly improve the outcomes in terms of lungs. The patient ends up intubated. 82 00:06:35,000 --> 00:06:37,000 If you guys have access to it, just get it as soon as you can. 83 00:06:37,000 --> 00:06:43,000 In summary, in this video, we focused on the massive transfusion protocol for trauma patients. 84 00:06:43,000 --> 00:06:49,000 When a patient remains hypotensive after receiving a significant amount of blood, activating MTP is crucial. 85 00:06:49,000 --> 00:06:57,000 Immediate blood transfusion is paramount, followed by FFP, aiming for a balanced 1 to 1 to 1 ratio. 86 00:06:57,000 --> 00:07:04,000 Guidelines suggest MTP activation after administering 20 ml per kilo of blood within an hour. 87 00:07:04,000 --> 00:07:08,000 Early pre-hospital transfusion might reduce mortality. 88 00:07:08,000 --> 00:07:16,000 Lastly, using tranexamic acid or TXA and MTP, combined with rapid resuscitation goal targeting, is important. 89 00:07:16,000 --> 00:07:19,000 Thank you for watching this video.