Managing Massive Transfusion Protocol During Cardiopulmonary Bypass in the Setting of Penetrating Traumatic Injury
A 34-year-old African American man was brought to the trauma resuscitation area with 2 gunshot wounds to his right anterior chest below his clavicle and his left back. On arrival, he appeared diaphoretic and in extremis, airway was intact, and he had breath sounds bilaterally. His heart rate was 154 bpm, he had palpable femoral pulses, and was hypotensive. His Glasgow Coma Scale was 14. Massive transfusion protocol (MTP) was initiated and a right femoral introducer catheter was placed. Bilateral chest tubes were placed without significant output. An expanding hematoma was noted extending from his sternal notch up his neck, which prompted intubation for airway protection. His focused assessment with sonography in trauma was negative. Chest and abdominal X-ray revealed mediastinal widening and 2 foreign bodies: 1 in the mediastinum and 1 in the left upper abdominal quadrant. He was transported to the operating room emergently.
The management of blood component ratios delivered during MTP while on CPB in the setting of trauma-induced hemorrhagic shock is complex and yet to be studied. Several factors need to be considered. First, cell salvage may not replace all of the blood lost in trauma patients on CPB as additional injuries outside of the operating field may exist. The literature referenced above indicating higher plasma to pRBC or platelet to pRBC ratios does not take this into account. Further, complexity is added when considering the impact heparinization and protamine administration has on trauma-induced coagulopathy. Ultimately, randomized multicenter trials are needed to further address optimal ratios of blood product transfusion during MTP in trauma patients on CPB.
