What is the recommended protocol for a patient requiring massive transfusion due to significant bleeding from trauma?

Massive Transfusion Protocol for Trauma

Immediate Protocol Activation and Hemorrhage Control

Activate the massive transfusion protocol immediately when massive hemorrhage is declared based on injury pattern alone, without waiting for laboratory confirmation or formal transfusion thresholds to be met. 1, 2

• Control obvious bleeding first using direct pressure, tourniquets for extremity hemorrhage, or hemostatic dressings—this is the paramount priority before any transfusion begins 3, 1
• Secure large-bore IV access with two large-bore peripheral cannulae, or consider 8-Fr central access in adults if peripheral access fails 1
• Administer high FiO₂ to ensure adequate oxygenation during hemorrhagic shock 1

Blood Product Resuscitation Strategy

Use a 1:1:1 ratio of red blood cells:fresh frozen plasma:platelets for all severely traumatized patients with massive hemorrhage. 3, 1, 2, 4

This recommendation is based on the PROPPR randomized controlled trial, which demonstrated that 1:1:1 ratios compared to 1:1:2 resulted in:

• Improved hemostasis and reduced exsanguination deaths 3, 4
• Comparable overall mortality but better control of bleeding 3
• No increase in complications such as ARDS, multiorgan failure, or acute kidney injury 3

Blood Product Administration Details

• Start with O-negative blood only if blood is needed immediately, limiting to 2 units maximum 1
• Transition rapidly to group-specific blood without performing antibody screening, as patients have minimal circulating antibodies during acute hemorrhage 3, 2
• For male patients, O RhD positive red cells are acceptable to preserve O-negative stock 1
• Administer all blood components using a 170-200 μm filter, with adequate warming devices at high infusion rates 1

Coagulopathy Prevention and Management

Prevent coagulopathy rather than treating established coagulopathy—this approach is superior and reduces mortality. 5

Target Laboratory Values

• Fibrinogen: Maintain >1.0 g/L at minimum; levels <1.0 g/L represent established hemostatic failure and predict microvascular bleeding 3, 2
• PT/aPTT: Keep <1.5 times normal; values exceeding this indicate established coagulopathy 3, 2
• Platelets: Target ≥75 × 10⁹/L throughout resuscitation 3, 1, 2

Early Plasma Administration

• Administer FFP early at 15 ml/kg if a senior clinician anticipates massive hemorrhage, to prevent dilutional coagulopathy before it develops 3, 2
• For established coagulopathy, more than 15 ml/kg of FFP will be required for correction 3

Fibrinogen Replacement

• Use fibrinogen concentrate at 30-60 mg/kg for rapid and predictable replacement, as it requires no thawing unlike cryoprecipitate 1
• Alternatively, use cryoprecipitate if fibrinogen concentrate is unavailable 3

Common Pitfall: FFP alone is impractical for increasing fibrinogen levels >1.5 g/L; the volume required increases exponentially as targeted fibrinogen levels rise, making fibrinogen concentrate or cryoprecipitate essential. 3

Laboratory Monitoring

• Obtain baseline samples immediately: FBC, PT, aPTT, Clauss fibrinogen, blood bank sample, biochemical profile, and blood gases 1
• Repeat coagulation studies every 4 hours or after 1/3 blood volume replacement, as coagulopathy develops rapidly 1

Institutional Requirements

Every hospital must have a major hemorrhage protocol in place that includes clinical, laboratory, and logistic responses. 3, 2

• Consider using locally developed "shock packs" in hospitals where massive hemorrhage is frequent 3
• Ensure blood products are readily available in the trauma bay when the patient arrives—faster replacement improves outcomes 6
• Use cell salvage in all cases of massive hemorrhage to reduce donor blood exposure 1

Post-Resuscitation Management

• Once bleeding is controlled, aggressively normalize blood pressure, acid-base status, and temperature 1
• Initiate standard venous thromboprophylaxis as soon as hemostasis is secured, as patients rapidly develop a prothrombotic state following massive hemorrhage 3, 1, 2
• Admit to critical care for ongoing monitoring of coagulation, hemoglobin, blood gases, and wound drains 1

Key Caveats

The 1:1:1 ratio is specifically validated for trauma patients; there is insufficient evidence to recommend fixed high-ratio transfusion strategies for non-traumatic massive bleeding. 4 The pathophysiology and coagulopathy patterns differ significantly between trauma and non-trauma hemorrhage, making extrapolation inappropriate without further evidence. 4