Hemorrhage and transfusion
Massive Hemorrhage Algorithm
Activating the massive transfusion protocol
1 Should you activate the MTP?
- Ongoing major bleeding with shock: SBP under 90, HR over 120, or ABC score 2 or more (penetrating, SBP 90 or less, HR 120 or more, positive FAST)
- Anticipating 4 or more units of red cells in an hour, or 10 in 24 hours
2 Balanced resuscitation
- Plasma, platelets and red cells 1:1:1 (or whole blood)
- Tranexamic acid 1 g IV within 3 hours of injury, then 1 g over 8 hours
- Limit crystalloid; warm every product (rapid infuser)
- Permissive hypotension (SBP 80–90) until bleeding is controlled, unless brain injury
3 Stop the bleeding
- Direct pressure, tourniquet, pelvic binder
- Surgery, interventional radiology or endoscopy as the source dictates
- Reverse anticoagulants (PCC, idarucizumab, protamine)
4 Monitor every 30–60 minutes
- Hgb, platelets, INR, fibrinogen, or viscoelastic testing (TEG/ROTEM) to guide products
- Fibrinogen under 150–200 mg/dL: cryoprecipitate
- Ionized calcium: keep over 1.1 mmol/L; give calcium with every few units (citrate)
- Potassium, pH, lactate and temperature (keep over 36 °C)
5 Deactivate the protocol
- Tell the blood bank so unused products return
- Switch to lab-guided transfusion (Hgb 7, platelets 50 if bleeding)
- Watch for TACO, TRALI and hyperkalemia
Drugs in this algorithm
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For education and exam preparation only. Follow your institution’s protocols. Study aid with typical adult values; follow your institution's protocols and current AHA guidelines.