What is the management protocol for massive hemorrhage requiring massive transfusion?

Massive Transfusion Protocol Management

Immediate Protocol Activation

Activate the massive transfusion protocol immediately when massive hemorrhage is declared without waiting for laboratory confirmation, as the nature of the injury typically alerts to probable massive hemorrhage before formal criteria are satisfied. 1

Critical First Actions

Hemorrhage Control

• Control obvious bleeding immediately using direct pressure, tourniquets for extremity hemorrhage, or hemostatic dressings, as this is the paramount priority in managing massive hemorrhage. 1, 2
• Pursue early surgical or obstetric intervention to arrest bleeding at the source, as damage control surgery may be necessary to control bleeding before complete physiologic normalization. 1, 3

Airway and Vascular Access

• Secure large-bore IV access with two large-bore peripheral cannulae, considering 8-Fr central access in adults or intraosseous access if peripheral fails. 1, 2
• Administer high FiO₂ to ensure adequate oxygenation during hemorrhagic shock, as hypoxia can exacerbate tissue injury. 1, 2

Hemodynamic Management

• Target systolic blood pressure of 80-100 mmHg until bleeding is controlled in patients without brain injury (permissive hypotension). 3
• Avoid vasopressors during active bleeding; reserve for after hemorrhage control. 3

Blood Product Resuscitation Strategy

Product Ratios

Administer blood products in a 1:1:1 ratio of red blood cells:fresh frozen plasma:platelets for severely traumatized patients with massive hemorrhage, as this approach has demonstrated improved survival compared to historical practices. 1, 2, 4

Blood Product Selection

• Start with O-negative blood only if blood is needed immediately, limiting to 2 units maximum, then transition to group-specific blood without antibody screening. 1
• For male patients, O RhD positive red cells are acceptable to preserve O-negative stock. 5
• Group-specific blood can be issued in approximately 10 minutes, which is a higher risk strategy but acceptable during massive hemorrhage when patients have minimal circulating antibodies. 5

Early FFP Administration

• Administer FFP early at 10-15 ml/kg to prevent dilutional coagulopathy if massive hemorrhage is anticipated. 5, 2
• For established coagulopathy, administer more than 15 ml/kg of FFP, with at least 30 ml/kg as a reasonable first-line response. 5, 2

Coagulopathy Management

Target Parameters

• Maintain fibrinogen >1 g/L, as levels below this threshold represent established hemostatic failure and predict microvascular bleeding. 1, 3
• Keep PT and aPTT <1.5 times normal, as values exceeding this indicate established coagulopathy requiring aggressive correction. 1, 3
• Target platelet count ≥75 × 10⁹/L throughout resuscitation, as thrombocytopenia below 50 × 10⁹/L is strongly associated with haemostatic compromise and microvascular bleeding. 5, 1, 2

Fibrinogen Replacement

• For hypofibrinogenemia, use fibrinogen concentrate at 30-60 mg/kg for rapid and predictable replacement, as it requires no thawing unlike cryoprecipitate. 5
• Alternatively, use cryoprecipitate, though treatment may be associated with delays due to thawing and transportation. 5

Antifibrinolytic Therapy

• Administer intravenous tranexamic acid in clinical situations where increased fibrinolysis can be anticipated, particularly in traumatic hemorrhage. 5, 6

Laboratory Monitoring

Initial Testing

• Obtain baseline samples immediately, including FBC, PT, aPTT, Clauss fibrinogen (not derived fibrinogen), blood bank sample, biochemical profile, and blood gases. 1, 2, 3

Ongoing Monitoring

• Repeat coagulation studies every 4 hours or after 1/3 blood volume replacement, as coagulopathy can develop rapidly in massive hemorrhage. 1
• Monitor and correct hypocalcemia and hypomagnesemia, which are often associated with massively transfused patients. 5, 4

Special Considerations

Consumptive Coagulopathy

• Anticipate consumptive coagulopathy in obstetric hemorrhage (particularly placental abruption and amniotic fluid embolus), cardiopulmonary bypass, massive trauma with head injury, and sepsis. 5
• Hyperfibrinolysis is particularly associated with obstetric hemorrhage, CPB, and liver surgery. 5

Anticoagulation Reversal

• For warfarin: Use prothrombin complex concentrate (PCC) at 25 u/kg for INR 2-3.9,35 u/kg for INR 4-5.9, or 50 u/kg for INR >6, plus intravenous vitamin K 5-10 mg. 5
• For unfractionated heparin: Reverse with protamine (1 mg protamine reverses 100 u heparin), typically 25-50 mg IV. 5
• For antiplatelet agents: Aspirin can be reversed by platelet transfusion; clopidogrel is only partially reversed by platelets. 5

Liver Disease

• Anticipate that patients with liver disease will develop clinically significant dilutional coagulopathy and haemostatic failure with bleeds less than one blood volume due to decreased production of coagulation factors and dysfunctional fibrinogen. 5

Post-Resuscitation Management

Immediate Post-Control Care

• Once bleeding is controlled, aggressively normalize blood pressure, acid-base status, and temperature. 1, 3
• Admit to critical care for ongoing monitoring of coagulation, hemoglobin, blood gases, and wound drains. 1, 3

Thromboprophylaxis

• Initiate standard venous thromboprophylaxis as soon as hemostasis is secured, as patients rapidly develop a prothrombotic state following massive hemorrhage. 1, 2, 3

Critical Pitfalls to Avoid

• Do not wait for laboratory results before administering blood products in obvious massive hemorrhage—the clinical scenario should lead management. 3
• Do not use derived fibrinogen levels—these are misleading; use Clauss fibrinogen only. 3
• Do not attempt to achieve normal blood pressure during active bleeding—permissive hypotension is appropriate until hemorrhage control. 3
• Avoid overdependence on group O RhD negative red cells, as this may adversely impact local and national blood stock management. 5