title: Protocols for massive blood transfusion: when and why, and potential complications.
abstract: OBJECTIVE
  An update paper on massive bleeding after major trauma. A review of protocols to address massive bleeding, and its possible complications, including coagulation abnormalities, complications related to blood storage, immunosuppression and infection, lung injury associated with transfusion, and hypothermia is carried out.
  
  
  METHODS
  Literature review and discussion with authors' experience.
  
  
  RESULTS
  Massive bleeding is an acute life-threatening complication of major trauma, and consequently its prompt diagnosis and treatment is of overwhelming importance. Treatment requires rapid surgical management together with the massive infusion of colloid and blood.
  
  
  CONCLUSIONS
  Since massive transfusion provokes further problems in patients who are already severely traumatized and anaemic, once this course of action has been decided upon, a profound knowledge of its potential complications, careful monitoring and proper follow-up are all essential. To diagnose this bleeding, most authors favour, as the main first choice tool, a full-body CT scan (head to pelvis), in non-critical severe trauma cases. In addition, focused abdominal sonography for trauma (FAST, an acronym that highlights the necessity of rapid performance) is a very important diagnostic test for abdominal and thoracic bleeding. Furthermore, urgent surgical intervention should be undertaken for patients with significant free intraabdominal fluid and haemodynamic instability. Although the clinical situation and the blood haemoglobin concentration are the key factors considered in this rapid decision-making context, laboratory markers should not be based on a single haematocrit value, as its sensitivity to significant bleeding may be very low. Serum lactate and base deficit are very sensitive markers for detecting and monitoring the extent of bleeding and shock, in conjunction with repeated combined measurements of prothrombin time, activated partial thromboplastin time, fibrinogen and platelets.
authors.affiliation: Department of Orthopaedic Surgery and Traumatology, Hospital Costa del Sol, University of Malaga, Autovía A-7, Km 187, 29603, Marbella, Malaga, Spain. eguerado@hcs.es.
authors.forename: E
authors.initials: E
authors.lastname: Guerado
authors.affiliation: Department of Haematology, Hospital Costa del Sol, 29603, Marbella, Spain.
authors.forename: A
authors.initials: A
authors.lastname: Medina
authors.affiliation: Department of Haematology, Hospital Costa del Sol, 29603, Marbella, Spain.
authors.forename: M I
authors.initials: MI
authors.lastname: Mata
authors.affiliation: Intensive Care Unit, Hospital Costa del Sol, 29603, Marbella, Spain.
authors.forename: J M
authors.initials: JM
authors.lastname: Galvan
authors.affiliation: Department of Orthopaedic Surgery and Traumatology, Hospital Costa del Sol, University of Malaga, Autovía A-7, Km 187, 29603, Marbella, Malaga, Spain.
authors.forename: M L
authors.initials: ML
authors.lastname: Bertrand
mesh_terms: D055371:Acute Lung Injury / Q000209:etiology / Q000517:prevention & control*; D001778:Blood Coagulation Disorders / Q000209:etiology / Q000517:prevention & control*; D001780:Blood Coagulation Tests; D001803:Blood Transfusion / Q000379:methods; D002985:Clinical Protocols; D004632:Emergency Medical Services; D006801:Humans; D009104:Multiple Trauma / Q000150:complications / Q000503:physiopathology / Q000628:therapy*; D019095:Point-of-Care Systems; D012151:Resuscitation / Q000379:methods*; D012771:Shock, Hemorrhagic / Q000209:etiology / Q000503:physiopathology / Q000628:therapy*; D065227:Transfusion Reaction
keywords: Abdominal bleeding; Chest bleeding; Damage control; External fixation; Femur fracture; Massive bleeding; Massive transfusion; Pelvis fracture