POTD: MTP and OBH in 123

Happy Friday!

This week's Wellness POTD will be about what keeps all of us well and alive each and every day: blood! Ok so not as flashy and fun, but hopefully this is a relatively quick and dirty review of massive transfusion protocol (MTP) and OB hemorrhage (OBH) at MMC.

TLDR of MTP

• MTP is initiated if there is (1) >4 units of pRBC transfused in 1 hour OR (2) replaced all of the patient's total blood volume in 24 hours OR (3) replaced half the patient's total blood volume in 3 hours OR (4) bleeding faster than 150 ml/min

• MTP is un-crossmatched blood

• Adult MTP 1st round is 4u pRBC + 4u FFP + 1u platelets, then 2nd round is the same + 10u cryoprecipitate

• MTP is activated by an attending physician

• Notify the blood bank of MTP activation by calling 3-8400 or 3-7651

TLDR of OBH

• OBH is defined as (1) >1000 ml blood loss in any delivery OR (2) >500 ml blood loss in vaginal delivery with sxs of hypovolemia

• Call a Code H for concern for OBH

• Stage 1 think IV access/fluids/uterotonics, stage 2 think consult MFM, stage 3 think OR, stage 4 think ACLS

Ok now for the longer and more rambly (but hopefully helpful?!) details within our protocol at MMC...

Massive Transfusion Protocol

I will try to summarize the MTP protocol that Dr. Marshall shared via email, which I am also attaching to this email, and will highlight relevant facts for our clinical use in the ED.

Adult MTP Indication

1) Transfused >4 units of pRBC in 1 hour w/ more blood needed

2) Expected to transfuse >50% of a patient's total blood volume in 3 hours (most adults have around 10-12 pints/units of blood in their body)

3) Expected to transfuse >100% of a patient's total blood volume in 24 hours

4) Bleeding faster than 150 ml/min

Pediatric MTP Indication

1) Expected to transfuse >50% of a patient's total blood volume in 3 hours

2) Expected to transfuse >100% of a patient's total blood volume in 24 hours

3) Bleeding faster than 10% total blood volume/min

MTP Initiation/Termination

• Activated by an attending physician

• Initiate MTP by using the red phone by the North Side charge nurse desk or by calling blood bank at 3-8400 or 3-7651

  • Information that must be included on the call is name, MRN, sex, DOB, location, diagnosis, and contact physician info

• Have a physician fill out the "Emergency Blood Transfusion/Massive Transfusion Request" form, section B, and send it to blood bank by messenger or pneumatic tube

• Send a lavender top blood specimen for ABO antibody screening and crossmatching of continued future transfusions

• Blood bank does their magic prepping and getting us the blood...

• "Crack the fridge" in resus 51 for emergency blood to bridge us while awaiting MTP blood

  • Charge nurse has the code to the fridge

  • ED fridge contains 2 whole blood + 8 units O- pRBC + 4 units O+ pRBC + 4 units FFP (no platelets)

  • The attending physician can decide whole blood vs. components

  • Use O+ for males and O- for females

• Have the attending physician be in close contact with the blood bank to anticipate continued need

• Terminate MTP by the attending physician notifying the blood bank OR automatically terminates 4 hours after MTP started

MTP Components

MTP Tips

• Try to balance your transfusions by hour 1 or 2 into MTP (1:1:1 ratio of pRBC:FFP:platelets)

• The 1 unit of apheresis platelets in MTP is synonymous with ~6 units of individual platelets

• Use blood warmers to prevent hypothermia

• Consider TXA for trauma

• Consider calcium repletion after 3 units of transfusion

OB/Postpartum Hemorrhage

OBH Definition

1) Cumulative blood loss of >1000 ml in c-section or vaginal delivery

2) Cumulative blood loss of >500 ml in vaginal delivery with sxs of hypovolemia

OBH Stages

Stage 1: normal vital signs --> IV, fluids, fundal massage, pitocin, add other uterotonics

Stage 2: normal vital signs but blood loss up to 1500 ml OR pitocin and 2 uterotonics started --> consult MFM, transfuse, add TXA, foley, uterine balloon/packing

Stage 3: abnormal vital signs OR blood loss >1500 ml OR 2 units pRBC transfused --> go to OR, MTP

Stage 4: cardiovascular collapse --> ACLS

"Code H" aka alert the OB troops

Code H is the trigger to get more people involved for any stage OBH. It can be activated by anyone by dialing 33 and stating you have a Code H. The people notified are: OBGYN inside attending, OBGYN outside attending, anesthesia attending, anesthesia resident, chief OB resident, any individual on OB codes list, nursing leadership, blood bank.

OBH Tips 

• Consider the 4 T's of OBH when treating these patients: Tone (uterine atony), Trauma (laceration, hematoma, inversion, rupture), Tissue (retained products), Thrombin (coagulopathy)

• Use the red OB hemorrhage kit in the fridge of resus 52 which has pre-made uterotonic meds and a cheat sheet for when to use each

• Get the pitocin running early

Happy transfusing,

Kelsey

Resources:

- MMC MTP and OBH protocol

- Dr. Nicky Chung POTD from 10/8/24

- Dr. Kat Pattee POTD from 5/15/24

POTD: Trauma Tuesday - Nailed it!

For my final Trauma Tuesday POTD, I’m going to cover the topic of open nailbed lacerations.

What really matters most on initial inspection is any disruption to the proximal nail fold and lunula, which would suggest damage to the germinal matrix. Your fingernail grows from the germinal matrix, so if there is any disruption to that, the answer is easy. Stop and consult hand surgery. This patient is going to need a germinal matrix graft which is beyond our scope as ED docs.

If any of these other findings are also present, hand surgery consultation would also be indicated:

-              Infected wounds

-              Disruption of digital tendons

-              Displaced or unstable finger fractures that may require ORIF

-              Complicated digit dislocations

-              Fingertip amputations that include loss of nail and/or bone and fingertip pulp

However, if you note that the proximal nail fold and lunula look largely intact and all you have is a laceration to the nailbed + an avulsed nail, you can take care of that!

In an open nailbed laceration, you need to remove the nail and suture the nailbed. Controversy exists regarding replacing the nail. Nail splinting has been traditionally recommended to maintain the proximal nail fold during healing, prevent scarring and nail deformity, reduce infection, and decrease pain during dressing changes.

The most recent NINJA RCT in 2023 did not show difference in cosmetic appearance or infection rate at 7-10 days whether or not the nail was splinted in children, though these findings did not reach statistical significance.

Steps

Laceration repair:

1. Perform a digital block and have patient soak fingertip in saline while block is taking effect.

2. Placing a digital tourniquet may help minimize blood in field during repair.

3. Remove fingernail by gently separating the underlying adherent nail bed from nail.

   • Insert scissors or hemostat in closed position between nail and nail bed at distal tip and advance slowly in proximal direction.

   • Open and spread instrument while maintaining tips against undersurface of nail to avoid further injury to nail bed

4. Gently irrigate nail bed with 100-200 cc of NS.

5. Repair nailbed using 6-0 absorbables (chromic gut or vicryl rapid)

   • Direct needle from distal to proximal when passing needle to avoid tearing nailbed tissue.

   • Can alternatively use dermabond. In meta-analyses, using tissue adhesives was considered as effective as sutures for nailbed lac repair.

To splint with original nail:

1. Gently clean nail in dilute solution of povidone iodine and NS.

2. Place 3-4mm diameter hole in center of nail using sterile needle, scalpel, or cautery to allow drainage of any blood.

3. Replace nail beneath the proximal fold and secure in place with 2-3 drops of tissue adhesive. Can also suture nail in place (video below shows how you can do this).

4. If original nail can’t be used, place a nonadherent splint with single thickness of sterile gauze, silicon sheeting, or sterile foil from suture packet and hold in place with absorbable 4-0 sutures through lateral skin folds or skin glue.

Also repair any other lacerations outside of the nailbed (finger pad or folds) with 4-0 or 5-0 absorbable sutures.

Remove the tourniquet, apply a protective dressing, and you’re done!

Prior to discharge:

Update Tdap

Leave dressing in place until follow up visit with hand surgery within 7 days.

Most up to date guidelines suggest AGAINST routinely administering empiric abx, but consider using it in animal/human bites, excessive wound contamination, or patients with vascular insufficiency or immunocompromised states. Several randomized trials have not shown any benefit to giving abx. 

Make sure the patient understands that the nail is there to maintain patency of the proximal fold and that it will fall off within 1-3 weeks. A new nail will grow completely in 3-12 months. Despite our best efforts, scarring may still impact nail regrowth.

TL;DR: Check out below for an EMRAP video on nailbed laceration repair that basically sums this all up.

https://www.emrap.org/episode/nailbed/nailbed

References

https://www.uptodate.com/contents/evaluation-and-management-of-fingertip-injuries

https://www.emdocs.net/evidence-based-approach-to-nailbed-injuries-ed-presentations-evaluation-and-management/

https://www.aliem.com/trick-trade-nail-bed-repair-tissue-adhesive-glue/

https://first10em.com/the-ninja-trial-do-you-replace-the-fingernail-after-nail-bed-repair/

POTD: How to read a CT of the c-spine

Hello everyone,

I’m going to review the ABCS of reading a c-spine CT in today’s Trauma Tuesday. It’s something we order a lot of in the ED, so it’s good to have a standardized approach, just like we do with CXRs.

A = alignment: Best evaluated in the mid-sagittal view, evaluate the 4 smooth curves formed by the anterior and posterior surfaces of the vertebral bodies and the bases/tips of the spinous processes.

B = bones: In addition to looking at the vertebral bodies and spinous processes for breaks or loss of height, pay special attention to the arches/ring of C1 and the dens of C2.

C = cartilage: Assess the spaces between each vertebra, looking for widening, narrowing, or asymmetry.

S = soft tissue: Look at the pre-vertebral soft tissues in the mid-sagittal slice. Note that the soft tissue contour should parallel the vertebral bodies and is narrow from C1-C4.

There’s a couple of “spaces” to be aware of which I think is much easier to see rather than explain in written form so in the references below is a link to a short, helpful video that explains all this while showing you it at the same time!

References

https://www.youtube.com/watch?v=XY9xpI3EHec

https://coreem.net/core/the-abcs-of-reading-c-spine-cts/