see also:

• massive blood transfusions
• Western Health - very detailed massive transfusion protocol (docx) - intranet only
• WH emergency blood management plan (pdf) - intranet only
• WH Critical bleeding and massive transfusion - intranet only

• actual or anticipated 4 units RBCs within 4 hours, + haemodynamically unstable, +/- anticipated ongoing bleeding, or,
• severe thoracic, abdominal, pelvic or multiple long bone trauma, or,
• major obstetric, GIT or surgical bleeding

• send baseline FBE, coagulation screen, biochemistry, ABGs, blood group
• notify pathology laboratory “Activate MTP”

• notify haematologist/transfusion specialist
• prepare and issue blood components as requested
• anticipate repeat testing and blood component requirements
• minimise test turnaround times
• consider staff resources

• liaise regularly with lab staff and clinical team
• assist in interpretation of results and advise on blood component support
• at Western Health, clinicians wanting clinical advice should contact the Dorevitch Haematologist via Dorevitch Heidelberg Switchboard 9244 0450

• assign a runner to transport specimens and blood components/products
• for traumatic bleeding, blood product ratios of 1:1:2 (platelets:FFP:packed cells) is no worse than 1:1:1 and might be more realistic in terms of practicalities of resus (PROPPR trial).
• request:
  • 4 units RBC
  • 2 units FFP
    • if the patient's ABO and Rh (D) group is unknown and FFP is required urgently, group AB plasma can be administered until there is time to complete ABO and Rh (D) testing.
• aim for permissive hypotension systolic BP 80-100mmHg BUT NOT if head injured
• avoid excessive crystalloid
• avoid hypothermia as this impairs coagulation
• if head injury, aim for platelet count > 100 x 10^9/L
• consider:
  • 1 adult therapeutic dose platelets if platelet count < 50 x 10⁹/L
    • ABO identical platelets are preferred, ABO non-identical platelets may be issued when ABO identical are not available. If Rh (D) Positive platelets are given to Rh(D) Negative patients, the use of Rh(D) Immunoglobulin (Anti D) may be required.
  • tranexamic acid (Cyclokapron) 1g load over 10min then 1 g infusion over 8 hours in trauma patients
  • if INR > 1.5 then give FFP 15ml/kg (discuss with lab to advise on number of units needed)
  • if on warfarin, add vitamin K, prothrombinex and FFP - see Mx of excessive INR or bleeding on warfarin Rx
  • cryoprecipitate 3-4g if fibrinogen < 1g/L (1.5g/L in pregnant patients)
    • if the patient's ABO and Rh (D) group is unknown and cryoprecipitate is required urgently group AB (or A if AB is not available) cryo can be administered until there is time to complete ABO and Rh (D) testing
  • rFVIIa:
    • should not be used routinely as lack of evidence for reducing mortality or morbidity
    • off licence use may be reasonable if uncontrolled bleeding in a salvagable patient and failed surgical/radiological procedures to control bleeding, and, adequate blood component replacement, and pH > 7.2 and temp > 34degC
  • if obstetric haemorrhage:
    • early DIC often present, consider cryoprecipitate
    • uterotonic agents and compression
    • EUA and repair
    • intrauterine tamponade
    • B lynch suture
    • arterial ligation
    • aterial embolisation
• once bleeding controlled, notify lab “cease MTP”
• in the event of any blood product being damaged and needing to be discarded that the product/bag must be returned to the transfusion laboratory so that issue records can be amended accordingly - this is required to ensure laboratory records comply with the 20 year donor to recipient traceability requirements