EAST 2017 #11: Use of Incompatible (Type A) Plasma For Massive Transfusion

Type AB plasma is considered “universal donor” plasma, as it contains no antibodies to red cells with either A or B antigens on their surface. Unfortunately, only about 4% of the US population have this blood type and can provide the product. Due to this shortage, some trauma centers have decided to use Type A plasma initially for massive transfusion, and switch to type specific plasma once patient blood has been typed and screened.

This works, since only about 13% of the population have red cells with B antigens on the surface. But are there any adverse effects in those patients who receive potentially incompatible plasma? The EAST Multicenter Study group performed a retrospective study using trauma registry and blood bank data from 5 trauma centers. They looked at adult patients who received plasma as part of the massive transfusion protocol (MTP) over a 4+ year period. Incompatible type A plasma transfusion was defined to occur if a patient had either Type B or AB blood.

Here are the factoids:

  • There were a total of 1212 patients in the study; 93% were compatible and 7% were incompatible type A initial transfusions
  • The usual trauma demographics were seen (young, male) and the average ISS was 25 (they triggered an MTP, remember?)
  • By chance, the incompatible group had a slightly higher ISS (29) and penetrating injury rate (45% vs 33%)
  • The incompatible group received significantly more plasma during the first 4 hours and during the first day
  • There was no difference in mortality sepsis, ARDS, thromboembolic events, or renal failure
  • Regression analysis showed that incompatible plasma was not a predictor of mortality or morbidity
  • There was one hemolytic reaction and one occurrence of TRALI, both in the compatible group

Bottom line: This is the largest study around on the topic, and it does not show any significant problems (at least the ones that were studied) with giving incompatible plasma in acute trauma. How can this be, you ask? Remember, only the first one or two units (the first MTP pack) is potentially incompatible. Hopefully, by the time the second pack is delivered, the blood has been typed. And these patients are potentially receiving multiple units of typed plasma after the initial transfusion which dilutes the incompatible, and multiple transfusions overall which may blunt their immune response. 

This is an important paper that all centers should consider as they update their massive transfusion protocols!

Questions and comments for the authors/presenters:

  1. The abstract states that 5 centers participated, but the tables only list 4. Please explain this.
  2. It is not stated explicitly whether all centers used type A plasma initially. Is this the case?
  3. This is important work! Have any other centers converted to initial use of type A plasma?

Click here to go the the EAST 2017 page to see comments on other abstracts.

Related post:

Reference: Use of incompatible type A plasma transfusion in patients requiring massive transfusion protocol: outcomes of an EAST multicenter study. Paper #16, EAST 2017.

Source: http://thetraumapro.com/2017/01/11/east-2017-11-use-of-incompatible-type-a-plasma-for-massive-transfusion/

Skull fractures with #POCUS

Have you ever used POCUS to diagnose a skull fracture? We talk about it briefly at EDE 2, although we focus on the distal radius, extremities, and some other bones a bit more. But POCUS is really useful for skull fractures. Of course, if you have ready access to a CT scan, its utility will be less. But the farther you get from a CT scanner, the more you might find yourself reaching for your probe, especially in a low risk patient, or a young patient. Here are a couple of fairly recent articles by Rabiner and Parri for the use of POCUS to diagnose skull fractures in children. And here is a case:

A 7 week old male was minding his own business when his playful 3-year-old brother dropped him…head-first…on a hardwood floor. The child cried right away. His (naturally) worried mom brought him to the ED. He had a fairly innocuous looking bruise to the right occiput. It was tender and the child cried whenever that area was touched. If the patient was 3 years old and had a harder skull, the management plan may have only been reassurance and that’s about it. But, at 7 weeks, the skull is relatively thin. But who wants to do a CT scan on a 7 week old? POCUS to the rescue! The bruise and surrounding area was scanned. The trouble with the infant skull is suture lines! They have an uncanny resemblance to a fracture. We all learn about suture lines in medical school, but a quick refresher of an online resource for the location of the suture lines might be in order before you check an infant for a skull fracture with POCUS. Here is this child’s scan:

There are 2 areas of the skull that look like a fracture. But the one on screen left is a normal suture line. The one on screen right is indeed a fracture. The giveaway was that each time the probe was placed directly over the apparent fracture line, the child cried.

A confirmatory elective ultrasound done in the radiology department yielded the same result. As well, their check of the intracranial contents yielded no evidence of intracranial hemorrhage. And yes, I will be checking for that myself if and when another similar case arises! The child was admitted for observation and did well.

Calcaneus Fractures

Calcanus fractures are relatively uncommon but knowledge of appropriate diagnostics and management is core EM.

Calcanus fractures are relatively uncommon but knowledge of appropriate diagnostics and management is core EM.

Foot and Ankle Bones (northcoastfootcare.com)

Foot and Ankle Bones (northcoastfootcare.com)

Definition: Fracture of the calcaneus bone

Mechanism

  • Traumatic axial loading is the most common cause (eg fall from height)
  • Can also occur in MVCs when the accelerator/brake pedal impacts the foot
  • Stress fractures seen with overuse from repetitive impact (e.g. runners)

Epidemiology

  • 2% of all fractures
  • Most frequently fractured tarsal bone
  • 90% occur in men between 21 and 45 years of age with majority being industrial workers
  • Approximately 10% are open fractures (Egol 2010)
The Calcaneus (joint-pain-expert.net/calcaneus)

The Calcaneus (joint-pain-expert.net/calcaneus)

Ecchymosis after Calcaneus Fracture (orthopaedicsone.com)

Ecchymosis after Calcaneus Fracture (orthopaedicsone.com)

Physical Exam

  • Moderate to severe heel tenderness
  • Swelling
  • Shortened wide heel with varus deformity
  • Ecchymosis around heel extending to arch is highly suggestive, may also see fracture blisters
  • Compartment syndrome occurs in 10% of calcaneal fractures and can result in clawing of the toes after recovery (Egol 2010)
  • Concomitant Achilles tendon rupture may be present

Calcaneus Fracture Classification (See Images in Gallery Below)

  • Extra-articular (subtalar joint)
    • 25% of all calcaneus fractures
    • Avulsion injury of:
      • Anterior process by bifurcate ligament
      • Sustenaculum tali
      • Calcaneal tuberosity (Achilles tendon avulsion)
  • calcaneus-bone-radiopaedia-orgIntra-articular
    • 75% of calcaneus fractures
    • 2 classification systems
      • Essex-Lopresti Classification
        • The primary fracture line runs obliquely through the posterior facet forming two fragments.
        • The secondary fracture line runs in one of two planes:
          • “Tongue-Type” Fracture
            • Axial plane beneath the posterior facet exiting posteriorly
            • This fracture tends to cause tension on the skin with possible necrosis. Consider an emergent orthopedics consult for all patients with this pattern
          • Behind the posterior facet in joint depression fractures
      • Sanders (based on CT)- based on number and location of articular fragments seen on the coronal CT image at the widest point of the posterior facet (E)
        • Type I: all nondisplaced fractures
        • Type II: two-part fractures of the posterior facet
        • Type II: three-part fractures with centrally-depressed fragment
        • Type IV: four-part articular fractures
Sanders Classification (foothyperbook.com)

Sanders Classification (foothyperbook.com)

Bohler Angle (orthobullets.com)

Bohler Angle (orthobullets.com)

Diagnostic Imaging

  • Standard X-rays: AP, lateral, oblique foot
  • Optional X-rays (See Image Gallery below)
    • Broden views: allows visualization of posterior facet
    • Harris View: visualizes tuberosity fragment widening, shortening, and varus positioning
    • AP ankle: demonstrates fibular impingement if lateral wall extrusion is present
  • Findings in calcaneal fractures:
  • Reduced Bohler angle
    • Created with lines drawn tangiental to anterior and posterior aspects of superior calcaneus
    • Normal is 20-40 degrees
  • Increased angle of Gissane
    • Formed by downward and upward slopes of calcaneus
    • Normal is 95-105 degrees
  • Non-contrast CT
    • Obtain when clinical suspicion of a fracture is high despite negative x-rays
    • Gold standard imaging test for any calcaneal fracture (except for stress fractures)
    • Will almost always be obtained for pre-operative planning but does not necessarily need to be obtained in the ED
Angle of Gissane (orthobullets.com)

Angle of Gissane (orthobullets.com)

Associated Injuries

  • Vertebral injuries secondary to axial loading injury (10%)
  • Contralateral calcaneal injury (10%) (Hatch)

ED Management

  • Provide analgesia
  • Complete neurovascular exam
  • Consider compartment syndrome
  • Can initially be placed in Bulky Jones dressing with supportive posterior splint to provide flexion
  • Conservative therapy (casting + nonweightbearing)
    • Casting and nonweightbearing for 6 weeks for calcaneal stress fractures
    • Casting and nonweightbearing for 10-12 weeks if:
      • Small extra-articular fracture (<1 cm) with intact Achilles tendon and <2 mm displacement
      • Sanders Type I (nondisplaced)
      • Anterior process fracture involving <25% of calcaneocuboid joint
      • Comorbidities that preclude good surgical outcome (smoker, diabetes, PVD)
  • All other fractures require surgical intervention

Prognosis: Relatively poor with overall 40% complication rate (malunion, subtalar arthritis, clawing of toes)

Take Home Points

  • Always suspect calcaneus fractures in patients with axial loading injuries to the lower extremities. If a calcaneus injury is found, look for concomitant fractures of the ankle and vertebrae.
  • Patients with calcaneal fractures will always be nonweightbearing on ED discharge
  • Watch out for compartment syndrome of the foot which occurs in 10% of calcaneal fractures and results in significant morbidity

References

  • Barrie J. (2013) Calcaneal fractures. [East Lancashire Foot and Ankle Hyperbook]. Retrieved from http://www.foothyperbook.com/trauma/calcanealFx/calcanealFxClassn.htm
  • Egol KA et al. Handbook of Fractures 4th ed. Lipincott 2010: 507-519.
  • Gitajn IL et al. Anatomic alignment and integrity of the sustenaculum tali in intra-articular calcaneal fractures. J Bone Joint Surg Am. 2014; 96(12): 1000-1005. PMID: 24951735.
  • Hatch D. Calcaneus Fractures. [OrthoBullets]. Retrieved from: http://www.orthobullets.com/trauma/1051/calcaneus-fractures

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ECG of the Week – 9th January 2017 – Interpretation

This ECG is from a 59 yr old male who presented with episodic chest pain for the last 2 weeks which had been constant for the last 1 hour. He has a past medical history of hypertension.

 
 
Click to enlarge


Rate:
  • ~125 bpm
Rhythm:
  • Regular
  • Sinus Rhythm
Axis:
  • Normal
Intervals:
  • PR - Normal (~180ms)
  • QRS - Normal (60ms)
Segments:
  • ST Elevation leads: I (0.5-1mm), aVL (1mm), V1 (1mm), V2 (8-9mm), V3 (4mm), V4 (1mm)
  • ST Depression leads: II, III, aVF, V5-6
Interpretation:
  • Anterior STEMI
 What happened ?

The patient was transferred for urgent angio which showed:
  • Left main 40% ostial lesion
  • LAD diffuse disease with severe mid disease and severe distal disease - PCI with DES x 2
  • Cx severe ostial
  • RCA Diffuse mild-mod disease
Post procedure echo:
  • Mod-severe segmental dysfunction with extensive anterior wall akinesis - EF 37%
  • No significant valvular dysfunction
The patient had an uneventful further in-patient stay.
References / Further Reading
 
Life in the Fast Lane
Textbook
  • Chan TC, Brady WJ, Harrigan RA, Ornato JP, Rosen P. ECG in Emergency Medicine and Acute Care. Elsevier Mosby 2005.