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International Journal of Medicine and Pharmaceutical Sciences (IJMPS) ISSN 2250 - 0049 Vol. 3, Issue 4, Oct 2013, 29-36 Š TJPRC Pvt. Ltd.

BLOOD TRANSFUSION IN TRAUMA PATIENTS IN RAS AL KHAIMAH, UNITED ARAB EMIRATES BEGUM SAIDUNNISA1, AGARWAL ANSHOO2, CHUDASAMA MEGHNA3 & RAIDULLAH EMADULLAH4 1

Chairperson Biochemistry, Ras Al Khaimah Medical and Health Sciences University, Ras Al Khaimah, UAE 2

Chairperson Pathology, Ras Al Khaimah Medical and Health Sciences University, Ras Al Khaimah, UAE 3

Doctor, LVIV National Medical University, Ukraine

4

Research Scholar, Ras Al Khaimah Medical and Health Sciences University, Ras Al Khaimah, UAE

ABSTRACT Introduction Traumatic injury is the leading cause of death for patients between the ages of 5 and 44. Timing of intervention is important, because hemorrhagic deaths occur very early, usually within the first 6 hours of admission. Over the last 40 years, transfusion therapy evolved from use of predominately whole blood to largely component therapy. Methods A 5-year retrospective study from 2007-2011, of trauma patients who received transfusion of blood components, information was retrieved by analyzing records from files of patients, available in the blood bank database of SAQR Hospital, Ras Al Khaimah, UAE. Results 17% (418 patients) of 2, 459 trauma patients received blood transfusions. Indications for blood transfusion in the desending order were head injuries, followed by limb fractures, blunt injuries to abdomen, thoracic cage and spinal cord. The age range of patients was 20-40 years, with more males receiving transfusion for trauma, and the majority of patients being UAE nationals. The overall mortality in transfused patients was 10%. During the years of this study, here was a significant reduction in the mean number of PRBC units and increase in utilization of FFP mean units/patient was observed. This was more evident in the group of more severely injured and blunt trauma patients. Conclusions In patients without hemorrhagic shock, the risk of transfusion outweighs any potential benefit. However, for patients with severe traumatic injury and hemorrhagic shock, the survival benefit with increased fresh frozen plasma and platelet transfusion likely far exceeds the risks associated with their use. Early and increased use of FFP, platelets, and RBC, 1:1:1 improved survival traumatic injury victims.

KEYWORDS: Traumatic Injury, Blood Component Therapy, Packed Red Blood Cell [PRBC], Fresh Frozen Plasma [FFP], Coagulopathy, Hemorrhage

INTRODUCTION Worldwide traumatic injury is the leading cause of death among persons between 5 and 44 years of age [Krug EG, et.al 2000] and accounts for 10% of all deaths [Murray CJ, et.al 1997]. Because trauma affects a disproportionate number of young people, the burden to society in terms of lost productivity, premature death, and disability is considerable. Despite


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Begum Saidunnisa, Agarwal Anshoo, Chudasama Meghna & Raidullah Emadullah

improvements in trauma care, uncontrolled bleeding contributes to 30% to 40% of trauma-related deaths and is the leading cause of potentially preventable early in-hospital deaths [Sauaia A, et.al, 1995 Holcomb JB, 2004 Kauvar DS, et.al 2005]. Trauma also known as injury [6 Campbell, (7th ed. ed.).2011] is a physiological wound caused by an external source. [Merriam Webster. 2013][Dictionary.com.2010] Can be either intentional (suicide and self-harm, violence, war) or accidental. The leading causes of traumatic death are blunt trauma, motor vehicle collisions and falls. [McGraw-Hill's EMT-Basic] Trauma can be classified by the affected area of the body.[Rosen's emergency medicine: 7th edition, Bonatti, H; et.al 2008] Polytrauma (40%) Head injury (30%) Chest trauma (20%) Abdominal trauma (10%) Extremity trauma (2%) Facial trauma, Spinal cord injury, Genitourinary system trauma, Pelvic trauma, Soft tissue injury. Major trauma, defined by an Injury Severity Score of greater than 15,[ Søreide, K.2009 ] can result in secondary complications such as circulatory shock, respiratory failure and death, and resuscitation of a trauma patient can often involve multiple management procedures. Over the past few years significant improvements have been made in the management of the injured patients, mainly due to advances in the various imaging modalities. Focused assessment with sonography for trauma (FAST) scan is routinely performed in the A/E and even in pre hospital phase. The introduction of the multidetecor computed tomography (MDCT) has brought up the next level in the trauma injuries recognition. MDCT allows the whole body to be scanned within five seconds (Chan 2009). Resuscitation of the trauma patient with uncontrolled bleeding requires the early identification of potential bleeding sources followed by prompt action to minimize blood loss, to restore tissue perfusion, and to achieve haemodynamic stability [Spahn DR, et.al 2005]. Fresh whole blood has long been thought of as the criterion standard for transfusion, but the advent of whole blood fractionation techniques subsequent to World War II provided a means of more efficient use of the various components (ie, packed red blood cells [PRBCs], fresh frozen plasma [FFP], individual factor concentrates, platelet concentrates, cryoprecipitate). As a result, current indications for the use of whole blood are increasingly narrow [Lewis J Kaplan,et.al 2012]. Coagulopathy is present in 25% to 38% of trauma patients on arrival to the hospital, and these patients are four times more likely to die than trauma patients without coagulopathy.[Brohi K,et.al2003 Rossaint R,e.al 2010] Standard coagulation therapy consists of fresh frozen plasma (FFP), platelet concentrate and, in some countries, cryoprecipitate [ Holcomb JB, et.al 2007 Ketchum L,et.al 2006]. One approach proposed for preventing exsanguination has been to treat patients with a fixed ratio of FFP to red blood cells (RBC), but the optimal value of this ratio is still under debate [ Borgman MA,et.al 2007 Maegele M,et.al, 2008 Teixeira PG,et.al 2009 Snyder CW,et.al 2009]. Recently, a high ratio of fresh frozen plasma (FFP) to packed red blood cells (PRBCs) has been shown to decrease mortality in massively transfused trauma patients and is currently recognized as the standard of care in some centers[ Brown LM,et.al 2011].

OBJECTIVES 

To study indications for blood transfusion and the correlation with types of injury along with demographic detailsin trauma patients at SAQR Hospital, Ras Al Khaimah.


Blood Transfusion in Trauma Patients in Ras Al Khaimah, United Arab Emirates



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To determine if blood product utilization has changed over time, a yearly trend was analyzed from the blood bank records

MATERIALS AND METHODS A 5-year retrospective study of trauma patients who received transfusion of blood components, information was retrieved by analyzing records from files of patients, available in the blood bank database of SAQR Hospital, Ras Al Khaimah, UAE. Other patient variables studied included age, gender, nationality, types of injuries and type of blood products transfused.

RESULTS Over 5 years period from 2007-2011, 17% (418 patients) of 2, 459 trauma patients received blood transfusions. The age range of patients was 20-40 years, with more males receiving transfusion for trauma than females, and the majority of patients being UAE nationals. The overall mortality in transfused patients was 10% (246 patients) [Figure 1]. Indications for blood transfusion were head injuries (45%), limb fractures (20%), and blunt injuries to abdomen (10%), thoracic cage (12%), and spinal cord (13%) [Figure 2]. There was no change in the proportion of patients receiving transfusions throughout the years;[Figure 3] however there was a significant 23.5% reduction in the mean number of PRBC units transfused. This was more evident in the group of more severely injured patients. The highest reduction in PRBC transfusion was seen in blunt trauma patients. During the years of this study, a significant increase in utilization of FFP was observed, with 40.7% increase of mean units/patient of FFP [Figure 4]. Aggressive utilization of FFP is one of the components of the evolving concepts of resuscitation which has gained acceptance recently and may have contributed to the decrease in PRBC requirements.

Figure 1

Figure 2


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Begum Saidunnisa, Agarwal Anshoo, Chudasama Meghna & Raidullah Emadullah

Figure 3

Figure 4

DISCUSSIONS Trauma comprises a noticeable global burden of health problems affecting nearly every population in the world Krug EG,et.al,2000). It has been stated that 50% of people face traumatic events at least once throughout their lifetime (Vazquez C, et.al 2005). Injuries, especially traffic injuries, are considered a major public health challenge (Akbari ME, et.al 2006). UAE has a great road network with 8 and 10 lane highways; the standard of driving can be appalling at times due to the prevalence of powerful expensive cars and opportunities to drive them fast. Road traffic injuries are the second major cause of death in the United Arab Emirates (UAE). One study in UAE showed Head injury was the most frequently noted type of injury (40.5%), followed by limbs injury (22.1%) and chest, abdomen and pelvic injuries (14.7%).The majority of victims were males and under the age of 35 years [Bener A et.al 1992] Our study also showed similar results. Injuries to the head featured predominantly and were the cause of death in many patients. Majority of victims were males and between 20-40 years of age. Coagulopathy in conjunction with hypothermia and acidosis is often referred to as the ‘lethal triad’ because of the high mortality [ Hardaway RM. et.al 1970; Hoyt DB et.al 1994; Lynn M, et.al 2002].Coagulopathy may exist in 25% of patients before arrival to the hospital. A study showed, brain injury and long bone fractures are particularly prone to developing coagulopathy. Shock appears to be the most important factor in the development of early coagulopathy. This condition is found in 25% of severely injured patients and carries a four-fold increase in mortality.[ Brohi K, et.al 2003; MacLeod JB, et.al 2003 Maegele M, et.al 2007]


Blood Transfusion in Trauma Patients in Ras Al Khaimah, United Arab Emirates

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Resuscitation of trauma patients with critical bleeding involves the infusion of large volumes of crystalloid and colloid followed by red blood cell (RBC) transfusion. However, RBC concentrates contain negligible amounts of platelets and coagulation factors. As a result, RBC transfusion, while improving oxygen transport, does not correct depletion of coagulation factors and platelets and can result in coagulopathy. Current management for coagulopathy-related bleeding is mainly based on transfusion of fresh frozen plasma (FFP), platelets, coagulation factor concentrates (fibrinogen and prothrombin complex concentrates) and, where available, cryoprecipitate. When coagulopathy is accompanied by hypothermia and acidosis, even adequate replacement may not be able to control the bleeding, resulting in exsanguination [ Ferrara A,et.al 1990] Coagulopathy occurs early in the post-injury period,[ Kuo JR, et.al 2004] and has been shown to be an independent predictor of mortality. [36, 37, 35, MacLeod J, et.al 2004 MacLeod et.al 2003;] Therefore, correction of coagulopathy may potentially decrease mortality in patients with severe trauma. Whole blood is fractionated into specific components, as follows: PRBC, FFP, platelet concentrates, and cryoprecipitate; FFP may be further fractionated into individual factor concentrates as well. Fractionation maximizes the clinician’s ability to rationally use the components of each donated unit while simultaneously limiting unnecessary transfusions. A specific product may also be transfused with less volume. Additionally, the individual components require different storage temperatures; therefore, fractionation allows more effective product management.[Kauvar DS, et.al 2005] Packed RBCs are almost always indicated when hemoglobin < 6 g/dL Clinical assessment of perfusion and oxygen delivery are used to determine if RBC transfusion is indicated with hemoglobin between 6 and 10 g/dL. Platelets transfusion in trauma patients with microvascular bleeding usually require regular platelet transfusions when the platelet count is < 50,000/mm3. Fresh Frozen Plasma (FFP) Indicated for control of microvascularbleeding when the PT or aPTT is > 1.5 times control. Indicated for control of microvascularbleeding in patients undergoing massive transfusion.[Practice guidelines for blood component therapy: report by the American Society 1996] Our study also showed increased incidence of head injury followed by limb fractures that are more likely to develop coagulopathy which could be the probable cause of increase utilization of FPP. Hospitals are encouraged to develop a massive transfusion protocol that stresses the proactive use of FFP and platelets along with RBC[ Hess JR, et.al 2008] . The use of ‘fresh’ (<24 h old) unrefrigerated whole blood instead of RBCs in trauma patients requiring massive transfusion has been proposed as means of overcoming coagulopathy.[ Erber WN,et.al 1996; Grosso SM,et.al, 2000; ] In an emergency situation fresh whole blood, especially in large amounts, is not readily available. This approach has many logistic problems. Moreover, as several countries have implemented universal leucodepletion, i.e. all blood units are leucodepleted before storage, whole blood which is leucodepleted is not really ‘whole’ as almost all platelets and some clotting factors are removed during the leucocyte filtration process [MacLennan S, et.al 2001]. Hence, the use of fresh whole blood may not correct massive transfusion-related coagulopathy and is a rather impractical option [D.R.Spahn, BJAVolume 95, Issue 2]. Plasma, platelets, and RBC transfusion have been associated with increased risk of allergic reactions, transfusionassociated acute lung injury, transfusion-associated cardiac overload, and ARDS [Gajic O,et.al 2006]


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Begum Saidunnisa, Agarwal Anshoo, Chudasama Meghna & Raidullah Emadullah

CONCLUSIONS In the present study only cases of traffic injuries were included. Injury mortality resulted mainly from head injury and haemorrhage. Blood component therapy predominates as the primary transfusion approach, by allowing components to be used in different patients. Studies have confirmed adverse outcomes like acute lung injury associated with transfusion of packed red blood cells (PRBCs) in trauma; however, little data are available regarding other blood product transfusion, such as fresh frozen plasma (FFP) and platelets. Current data indicate that the early identification of coagulopathy and its treatment with RBCs, fresh frozen plasma, and platelets in a 1:1:1 unit ratio accompanied with rapid hemorrhage control may improve survival I patients with severe traumatic injury and life-threatening bleeding. Our study showed increased incidence of head injury followed by limb fractures that are more likely to develop coagulopathy which could be the probable cause of increase utilization of FPP an evolving treatment modality of resuscitation which has gained acceptance globally.

ACKNOWLEDGEMENTS Blood bank, SAQR Hospital, Ras Al Khaimah. No funds or grants from any source were used to conduct this study.

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