Tackling the ‘bloody vicious cycle’

NHS could learn a great deal from the example set by the military in reducing mortality. The way forward was discussed at two recent conferences: ‘Trauma Update’, hosted by the European Society of Intensive Care Medicine, Intensive Care Society and Society of Critical Care Medicine, at The Royal Society, London; and ‘Disaster planning and management – are we prepared?’, hosted by the Anaesthesia and Critical Care Medicine Sections, Royal Society of Medicine, London. Speakers at both conferences highlighted the significance of tackling the ‘lethal triad’ of coagulopathy, hypothermia and acidosis, while optimising transfusion protocols.

Coagulopathy, transfusion and the military experience

Speaking at the conference on disaster planning, Major Nick Tarmey examined the question: ‘what can the NHS learn from the military’s experience of massive transfusion and coagulopathy?’ A specialist registrar in anaesthetics and intensive care medicine, Ministry of Defence Hospital Unit, Portsmouth, Major Tarmey commented: “The so called ‘bloody vicious cycle’ of coagulopathy, hypothermia and acidosis has long been recognised. However, it has only been recently understood that coagulopathy occurs earlier, before patients have the chance to become cold or haemodiluted.” A significant proportion of civilian trauma patients arrive in the Emergency Department already coagulopathic, which is associated with higher mortality. This has led to the development of ‘damage control resuscitation’, he explained: “In the military, this begins at the site of wounding – by ‘turning off the tap’ and stopping bleeding, keeping on top of coagulopathy and not letting it develop in the first place (if possible), as well as maintaining tissue oxygenation. “At the point of wounding, patients are given the right treatment from the very start. In catastrophic external haemorrhage, this starts with limb tourniquets. Evacuation is prioritised over definitive stabilisation. In the context of rapid evacuation, patients are only given fluid if the radial pulse is absent and certainly not delaying evacuation to the field hospital for ‘the benefit of trying to get a cannula into the patient’. “The medical emergency response team are in-bound as there is effective communication on the ground, with a properly prepared team that is able to respond quickly,” he continued. Major Tarmey added that the medical emergency response team fill a ‘therapeutic vacuum’ between the field care and the emergency department, by having an appropriately skilled, doctorled, pre-hospital team that can make decisions and pass back effective communication right from the start. Haemorrhage control is also achieved early, to the best possible pre-hospital standard. “We are able to give pre-hospital transfusion and deliver this quickly,” said Major Tarmey. “It is neither ‘stay and play’ or ‘scoop and run’ – rather we are able to move quickly and give effective treatment on the way. In the emergency department, the trauma team that meet the patient are not shocked or surprised by what they find. They already have a good idea of what to expect from the prehospital information they have received via radio, which is updated in a structured report when the patient arrives.” Depending on the mechanism of injury and the details of the report, the patient will receive blood and fresh frozen plasma (FFP) via a Belmont rapid infusion system. He stressed that a key approach to damage limitation resuscitation is the military’s UK ‘massive transfusion protocol’. Major Tarmey revealed that a 1:1 ratio of FFP to red blood cells (RBC) is used, delivered in pre-prepared packs, which has been supported by the findings of a paper by Borgman et al (2007).3 This paper highlighted the fact that patients, who received plasma or a plasma to RBC ratio close to 1:1, had improved survival compared to patients who received standard transfusion therapy of plasma to RBC ratios of 1:4 or greater. However, he acknowledged that the optimal ratio of FFP to red blood cells is still under discussion. “In the military, we are reassured by the good results that are achieved using a 1:1 ratio, but we are also looking at ways of switching more quickly to a tailored transfusion. What we have to consider, with our patients, and at the rate they are bleeding, is the fact that we are never going to be able to have a totally individualised transfusion from the start. “However, one way of individualising care beyond this initial period of extremely fast transfusion, is coagulation testing using thromboelastometry,” he continued. Located in the operating room, a Rotem machine is used by the surgical and anaesthesia team for haemostasis testing. The trace that is produced provides helpful information – including: the time to clot formation; the maximum clot strength achieved; the ability to differentiate between a lack of platelet function and a lack of fibrinogen; as well as an impression of the degree of fibrinolysis. “We are proud of the results we have been able to achieve in massive transfusion. A study has shown that out of 59 patients, who received massive transfusion at Camp Bastion, in 2009, there was an 86% overall survival rate. Impressively, 5 out of 7 patients who needed a transfusion of over 100 units actually survived to discharge.”4 Major Tarmey stressed that the key to improving survival is effective leadership and teamwork: “It is important to get the senior sub-specialties involved quickly. Everyone knows exactly what they need to be doing. There is a streamlined passage with properly rehearsed decision making, in getting the patient from the emergency department to the operating room. “In the operating room, there is continuity of care – the same anaesthetists and surgeons bring the patient through, so there are no ‘gaps’ – everyone knows already what has been given; the surgeons know exactly what they are dealing with. “We adhere to the damage limitation resuscitation protocol principles. There is no need to fight battles with people who do not understand, that try and perform a definitive repair that is going to take five hours on an unstable patient that cannot tolerate it. “Point-of-care coagulopathy monitoring means we can keep on top of coagulopathy before it really has a chance to develop and, if it does develop, we can intervene quickly, with a blood bank that understands what we are talking about and have the blood products that we request. Finally, nothing is lost in translation between anaesthesia and critical care. Critical care doctors come into theatre to talk to us. The patient has streamlined care from the start to the finish.” He argued that point-of-care coagulopathy monitoring could be cost effective in a larger NHS setting, while there were many aspects of the military model described that could be implemented, with a small increase in resources, throughout most settings. “We have made significant progress over the last 10 years in managing coagulopathic bleeding. I believe the NHS can do the same,” he concluded.