What is the protocol for managing massive transfusion?

Massive Transfusion Protocol

Activate your institutional massive transfusion protocol immediately when massive hemorrhage is anticipated or confirmed, and begin resuscitation with blood products in a 1:1:1 ratio of RBC:FFP:platelets while simultaneously controlling the bleeding source. 1, 2

Immediate Protocol Activation

Declare the massive transfusion situation immediately when you anticipate 1-1.5 blood volumes may need infusion acutely or within 24 hours—do not wait for laboratory confirmation or formal thresholds to be met. 3, 2 The nature of the injury pattern itself should trigger activation. 1

Critical Initial Actions (First 5 Minutes)

• Control obvious bleeding through direct pressure, tourniquets, or hemostatic dressings as the paramount priority. 1, 4
• Secure large-bore IV access: 8-Fr central access is ideal in adults; use intra-osseous or surgical venous access if peripheral fails. 3, 4
• Administer high FiO₂ to ensure adequate oxygenation. 1, 4
• Send baseline laboratory tests: FBC, PT, aPTT, Clauss fibrinogen (not derived), and cross-match. 3, 1 Use near-patient testing (TEG or ROTEM) if available for rapid coagulation assessment. 3, 4

Blood Product Resuscitation Strategy

The 1:1:1 Ratio Protocol

Administer blood products in a 1:1:1 ratio of RBC:FFP:platelets for severely injured patients with massive bleeding—this military-derived approach has shown improved survival in observational studies. 1, 2, 5 This balanced ratio prevents dilutional coagulopathy and approximates whole blood. 6, 7

Specific Product Administration

• Begin early FFP at 10-15 ml/kg to prevent dilutional coagulopathy before it develops—do not wait for coagulation test results. 1, 2
• Use warmed blood products exclusively: Start with O-negative blood if needed immediately, transition to group-specific (which can be issued without antibody screen in massive hemorrhage), then cross-matched blood. 3, 4, 2
• Maintain platelet count ≥75 × 10⁹/L throughout resuscitation. 3, 1, 2

Critical Pitfall to Avoid

Do not administer excessive crystalloid—this causes dilutional coagulopathy and worsens outcomes. 4 Fluid resuscitation in massive hemorrhage means warmed blood and blood components, not crystalloid. 3

Management of Coagulopathy

Fibrinogen Replacement

Target fibrinogen levels >1 g/L using fibrinogen concentrate or cryoprecipitate—fibrinogen <1 g/L represents established hemostatic failure and predicts microvascular bleeding. 1, 4, 2 Established coagulopathy requires more than 15 ml/kg of FFP to correct. 3, 1

Coagulation Monitoring

• Use Clauss fibrinogen (not derived fibrinogen, which is misleading). 3
• Monitor PT/aPTT: Values >1.5 times normal represent established hemostatic failure. 4
• Utilize TEG or ROTEM if available for real-time coagulation assessment and goal-directed therapy. 3, 5

Active Warming and Physiologic Optimization

Actively warm the patient and all transfused fluids using approved blood warming devices with visible thermometers and audible warnings—hypothermia exacerbates coagulopathy. 3, 4 Warming devices must be available in all emergency rooms and theatre suites, allowing adequate warming at high infusion rates. 3

Permissive Hypotension Until Bleeding Controlled

Restore organ perfusion but do not attempt to achieve normal blood pressure initially—aggressive normalization before bleeding control worsens outcomes. 3, 4 Once bleeding is controlled, aggressively normalize blood pressure, acid-base status, and temperature, but avoid vasopressors. 3, 4

Definitive Hemorrhage Control

Surgical Intervention

Consider surgery early—damage control surgery may be necessary, limited to controlling bleeding before complete physiologic normalization. 3, 4 Surgery may need to be interrupted and limited to "damage control" until bleeding is controlled and abnormal physiology can be corrected. 3

Imaging and Diagnostics

• Obtain rapid imaging (ultrasound, radiography, CT) or focused assessment with sonography for trauma if the patient is sufficiently stable. 3, 4
• Alert the theatre team about the need for cell salvage autotransfusion. 3, 4

Organizational Structure

Team Roles

Designate a team leader (usually the most senior physician) who declares the massive hemorrhage situation and coordinates management. 3, 2 Appoint a communications lead whose sole role is communicating with laboratories and other departments. 3

Allocate a dedicated member to convey blood samples and products between laboratory and clinical area—this person should be in constant radio communication. 3

Post-Resuscitation Management

Critical Care Admission

Admit to critical care for ongoing monitoring of coagulation, hemoglobin, blood gases, and wound drain assessment to identify overt or covert bleeding. 3, 1

Venous Thromboprophylaxis

Commence standard venous thromboprophylaxis as soon as hemostasis is secured—patients rapidly develop a prothrombotic state following massive hemorrhage. 3, 1, 4, 2 Temporary inferior vena cava filtration may be necessary. 3

Electrolyte Monitoring

Monitor and correct electrolyte abnormalities, particularly hypocalcemia from citrate toxicity, which can cause cardiac dysfunction. 1, 4

Common Pitfalls

• Delaying protocol activation increases mortality—activate immediately when massive hemorrhage is anticipated, not after formal thresholds are met. 1, 4
• Waiting for laboratory results before administering blood products in obvious massive hemorrhage increases mortality—begin transfusion based on clinical assessment. 1, 4
• Using hemoglobin level as the sole trigger for transfusion fails to account for the dynamic nature of hemorrhagic shock. 4
• Attempting to achieve normal blood pressure before bleeding control worsens outcomes—use permissive hypotension until hemorrhage is controlled. 3, 4