Clinical Tools

Massive Transfusion Protocol

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Activate Massive Transfusion Protocol

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Activate MTP per institutional criteria: anticipated need for 10+ units pRBC in 24 hours, or 4+ units pRBC in 1 hour, or clinical judgment of exsanguinating hemorrhage. Contact blood bank immediately.

Transfuse 1:1:1 Ratio

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Initial transfusion in 1:1:1 ratio (pRBC : FFP : platelets). Standard MTP cooler pack: 6 units pRBC, 6 units FFP, 1 apheresis platelet unit. Transfuse uncrossmatched O-negative (or O-positive for males) pRBC if type-specific blood is unavailable.

Tranexamic Acid (TXA)

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Tranexamic acid (TXA): 1 g IV over 10 minutes, must be given within 3 hours of injury. Follow with 1 g IV over 8 hours. Do not administer after 3 hours from injury (CRASH-2 showed potential harm).

Laboratory Monitoring

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Send labs: CBC, PT/INR, PTT, fibrinogen, ionized calcium (iCa), ABG with lactate. Repeat every 30-60 minutes. Use TEG (thromboelastography) or ROTEM (rotational thromboelastometry) if available for goal-directed therapy.

Maintain Ionized Calcium

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Maintain ionized calcium (iCa) above 1.0 mmol/L. Citrate in blood products chelates calcium. Administer calcium chloride 1 g IV (central line preferred) or calcium gluconate 3 g IV per approximately 4 units of blood products. Monitor iCa frequently.

Maintain Fibrinogen

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Maintain fibrinogen above 150 mg/dL. Administer cryoprecipitate 10 units if fibrinogen is low. Alternative: fibrinogen concentrate (RiaSTAP) 70 mg/kg if available.

Maintain Normothermia

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Maintain core temperature above 36 degrees C using fluid warmers, forced-air warming blankets, and increased ambient room temperature. Hypothermia worsens coagulopathy, forming the lethal triad with acidosis and coagulopathy.

Permissive Hypotension

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Target systolic blood pressure 80-90 mmHg (permissive hypotension) until definitive surgical hemorrhage control is achieved. This reduces ongoing blood loss. NOT applicable in traumatic brain injury (TBI) -- maintain SBP above 100 mmHg in TBI patients.

Reassess and Deactivate MTP

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Reassess for MTP deactivation when hemorrhage is controlled. Criteria: stable hemodynamics, decreasing transfusion requirements, surgical hemostasis achieved. Notify blood bank to return unused products and resume standard ordering.

Source: ASA Task Force, EAST Guidelines, ACS TQIP

Limitations

  • This protocol is a reference aid and does not replace clinical judgment.
  • Institutional MTP activation criteria and cooler contents may vary.
  • TEG/ROTEM availability and expertise is institution-dependent.
  • Permissive hypotension is contraindicated in traumatic brain injury.
  • Blood product availability may be limited -- communicate early with blood bank.

References

  1. American College of Surgeons. ACS TQIP Massive Transfusion in Trauma Guidelines. 2014.
  2. Holcomb JB, et al. Transfusion of plasma, platelets, and red blood cells in a 1:1:1 vs a 1:1:2 ratio and mortality in patients with severe trauma: the PROPPR randomized clinical trial. JAMA. 2015;313(5):471-482.
  3. CRASH-2 trial collaborators. Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo-controlled trial. Lancet. 2010;376(9734):23-32.
  4. Eastern Association for the Surgery of Trauma (EAST). Practice Management Guidelines for Massive Transfusion. J Trauma Acute Care Surg. 2017.