Does hemoglobin matter when deciding to transfuse a trauma patient?

Started by tdod
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tdod

tdod

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During trauma resuscitation is any attention paid to hemoglobin levels [i.e. "Hb is 10.0 so don't transfuse PRBC"], or is the decision exclusively about hemodynamics and circulation exam?

I assume that a low Hb would indicate transfusion requirement, so my main question is would a normal Hb ever prevent transfusion?

Thanks!
 
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tdod said:
During trauma resuscitation is any attention paid to hemoglobin levels [i.e. "Hb is 10.0 so don't transfuse PRBC"], or is the decision exclusively about hemodynamics and circulation exam?

I assume that a low Hb would indicate transfusion requirement, so my main question is would a normal Hb ever prevent transfusion?

Thanks!
Click to expand...
Hct and Hb do not change in the setting of acute blood loss.
 
If they are hypotensive due to blood loss, do you need to replace the blood with fluid to dilute the remaining blood and cause coagulopathy or do you need to replace the lost blood with blood?

Hemoglobin is a concentration, so in an acute blood loss setting there hasn't been time to replace the volume loss with fluid so the concentration shouldn't change until you give fluid or they have time to hydrate.
 
skougess said:
Let me ask you a question to answer your question. If I drained you of 99.99% of your blood and then tested the last drop left in you, what would your hemoglobin read?
Click to expand...
I understand your point and I agree with you in theory... However, whenever I argued that point to an OB-Gyn attending during a zoom lecture she said I was wrong and my peers agreed with her.
 
tdod said:
I understand your point and I agree with you in theory... However, whenever I made this point to an IM attending during a zoom lecture she said I was wrong and my peers agreed with her.
Click to expand...
That's because she is IM and not used to trauma or resuscitation. Though it is concerning as the same principle applies in massive GI bleeds. She is wrong. You can reference Harrison's if you need to, though challenging an attending is not the best idea as a student.

Kasper, Dennis L., et al., editors. "TRANSFUSIONS." Harrison's Manual of Medicine, 19th ed., McGraw Hill Inc., 2017.

*I see you updated it to OB-GYN. The etiology of bleeding in OB vs trauma or GI bleeds is different and easier to stabilize. If they are no longer bleeding and their vitals are stabilized, they won't deteriorate further unlike trauma and GI where they can still be bleeding from somewhere. Once OB bleeding stops, the problem is solved and young/healthy people will make more RBCs. The fluid shifts post partum also play a role in affecting the concentration and the management is different, but the concepts are similar. However, you will see OB transfusing a hypotensive post partum hemorrhage if they are still bleeding.

Apollyon said:
Isn't the Hct the concentration, as it's the percent of blood that is RBCs?
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Hemoglobin is g/dL which is a concentration and hematocrit is the percentage of RBCs. Both are calculated from the same thing.
 
Last edited:
tdod said:
I understand your point and I agree with you in theory... However, whenever I argued that point to an OB-Gyn attending during a zoom lecture she said I was wrong and my peers agreed with her.
Click to expand...
If you're talking about Hgb's and blood loss in post-partum OB patients, it's much different than post-trauma blood loss. OB's will send home young, healthy post partum patients with very low hemoglobins and without transfusing. That's because the timing, physiology and percent likelihood of undetected ongoing bleeding are totally different in the two patient populations. Perhaps that's why you're getting different answers from the car accident doctors, than the baby-birthing doctors.
 
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I'm confused. @clibby Your quoted post from @tdod says "whenever I argued that point to an IM attending...", but the original post says "OB-Gyn" and is quoted as such by @Birdstrike .

@tdod Did you edit your original post immediately (as there is no edit history) or @clibby did you change OB-Gyn to IM?
 
Hgb starts dropping within 10-30 minutes. It may take 24-48 hours to hit a nadir.

The faster it drops, the bigger the loss. You can use this to predict need for blood when you look at the whole situation.

Example: major trauma healthy male with suspected internal bleeding, time since injury 30 minutes. You get a hgb upon arrival that is 10. You should probably prepare to transfuse because he is rapidly headed downward assuming he had a normal hgb prior to the injury.

Therefore to answer your question we need to know two things: time since injury and estimated or actual blood loss. If someone comes in bleeding everywhere after getting stabbed multiple times 10 minutes ago, they may require a transfusion with a normal hgb. If someone comes in after an MVC with some mild intraabdominal bleeding but their hgb is 12 (normally say 14) and this happened yesterday, they probably won’t require a transfusion.
 
southerndoc said:
I'm confused. @clibby Your quoted post from @tdod says "whenever I argued that point to an IM attending...", but the original post says "OB-Gyn" and is quoted as such by @Birdstrike .

@tdod Did you edit your original post immediately (as there is no edit history) or @clibby did you change OB-Gyn to IM?
Click to expand...
I made no such change. Ain't nobody got time for that!
 
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tdod said:
I understand your point and I agree with you in theory... However, whenever I argued that point to an OB-Gyn attending during a zoom lecture she said I was wrong and my peers agreed with her.
Click to expand...
I believe you are a med student.

#1 - This OB doc has no understanding of critical care medicine. Period. Just the fact that she believes a normal H/H in the setting of acute blood loss never requires a transfusion is malpractice.
#2 - Some of your peers have no clue either thus they are med students. Some thinks she is a quack and just stayed quiet. Some thinks she is a quack and just agreed with her to get brownie points.
#3 - You are a med student and no matter what you are wrong esp if it will embarrass said attending.
#4 - As an attending, if I heard her say this I would not argue and just tell her in private she was wrong. No need to embarrass an attending and show how clueless she is with critical care medicine.
#5 - Bottom line is it doesn't matter what the situation or how the blood loss happened. If I think someone is unstable b/c of blood loss, they are getting blood/IVF no matter if they have a GI bleed, GSW, nose bleed, belly bleed, delivery.
 
My last transfusion was a hemoglobin of 12. The nurse was getting pretty upset at me lol.

Also, the initial hemoglobin in a large active bleeding patient is only useful in understanding baseline reserve. Someone with a hemoglobin of 15 can lose a lotttt of blood before they crash and burn without a transfusion and you could technically get away with volume resuscitation with fluids because of significant reserve. But obviously at some point you have to stop replacing blood with water.

But always treat the patient and not the number. Hypotensive, tachy, bleeding patient should get blood.
 
I remember some stupid ER metric 10 yrs ago where I had to give a reason for transfusing blood above hgb 7. Big brother is always watching.
 
The correlation between a patient's hemoglobin and circulating blood volume in the setting of acute blood loss is going to depend on a lot of variables. A low hemoglobin early after injury has been associated with increased severity of blood loss but it would be foolish to ignore other clinical information indicating high blood loss or ongoing bleeding just because the hemoglobin is normal.
 
emergentmd said:
I remember some stupid ER metric 10 yrs ago where I had to give a reason for transfusing blood above hgb 7. Big brother is always watching.
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We have to give a reason for every transfusion outside of massive transfusion and trauma alerts as part of the blood stewardship programs, but one of the criteria is "estimated blood loss >25%" and another is "Other". The inpatient side has too many "older" docs transfusing chronic anemia not just >7.0, but >8.0 and <10.0.
 
clibby said:
We have to give a reason for every transfusion outside of massive transfusion and trauma alerts as part of the blood stewardship programs, but one of the criteria is "estimated blood loss >25%" and another is "Other". The inpatient side has too many "older" docs transfusing chronic anemia not just >7.0, but >8.0 and <10.0.
Click to expand...
Oh yeah, especially love the nephrologists that keep transfusing these dialysis patients. Not sure what they’re trying to accomplish by transfusing chronic anemia of 8, there’s documented no mortality benefit to doing that.
 
A thorn in my side is the occasional patient sent in by PCP or specialist to the ED for a transfusion of some Hgb level that doesn’t come close to meeting any transfusion criteria written after 1996. Not too long ago had a chronic dysfunctional uterine bleeding patient sent in for Hgb 8.5 for a pRBC transfusion. No medical problems, not actively bleeding, just “fatigue”. What the hell do I do with that, other than dissapoint the patient and send them home.
 
tdod said:
During trauma resuscitation is any attention paid to hemoglobin levels [i.e. "Hb is 10.0 so don't transfuse PRBC"], or is the decision exclusively about hemodynamics and circulation exam?

I assume that a low Hb would indicate transfusion requirement, so my main question is would a normal Hb ever prevent transfusion?

Thanks!
Click to expand...

Not in the first 30 minutes of resus. Better to use something like shock index (HR vs SBP...if HR > SBP then shock index > 1 and is a pretty good indication to transfuse).

Most important thing is to figure out what's bleeding and stop it if possible. If it's an extremity apply pressure! If it's internal then surgery has to stop it or manage it.
 
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