Appropriate Initial Interventions
√ Intravenous access→ 2 large bore IVs &/or CVC
√ Crystalloid→ 3:1 ratio to blood loss
√ Labs → T&S, CBC, coagulation, lytes, ionized Ca
acid/base status – communicate urgency 4-4066
√ Continuous monitoring → VS, Intake/Output
√ Aggressive re-warming
√ Prevent/reverse acidosis
√ Correct hypocalcemia →CaCl 1 gm IV slowly
√ Transfuse with unmatched RBCs on hand
Points of Emphasis
Identify & Manage Bleeding
Collect Type & Screen, CBC and Coagulation Samples – Deliver STAT
4U RBCs transfused in ≤ 4 hours and ongoing major bleeding
OR
6U RBCs transfused in ≤ 24 hours and ongoing major bleeding
MD ORDERS MTP ACTIVATION
Other Considerations:
√ Heparin reversal → Protamine 1 mg IV per
100U of heparin
√ Warfarin reversal → Prothrombin Complex
1500 IU and Vitamin K 10 mg IV
√ CRF & Von Willebrand’s → DDAVP 0.3 mcg/kg
IV x1
√ Intraoperative cell salvage
√ Activated Factor VIIa→ Niastase RT™(40 mcg/kg)
Tranexamic acid 1 gm IV bolus, then 1 gm IV infused over 8 hours3
Within 3 hours of injury
ASSIGN ONE clinical team member to request MTP from TM 4-1367
PROVIDE Patient name and sex, RHRN, location, ordering physician
RECORD name of TM technologist you are speaking with
ARRANGE for pick up of pack (send unit staff for expedited pick up)
THRESHOLD
Aim for Hgb ≥ 100 in
Hgb ≥ 70 is sufficient
bleeding
in most stable noncoagulopathic patient bleeding patients
FP
If INR greater than 1.5 Give 2 units of FP
Platelets
Cryoprecipitate
Give 1 dose platelets.
If less than 100,000 or Platelets should drip
freely and not be
projected to be soon
transfused using a
less than 100,000
warmer or
pressurized infuser.
Fibrinogen less than
1.5 – 2 g/L OR
evidence of
microvascular
bleeding
√ 6 Units RBCs
Give 1 cryo pool (10U)
NOTE: 4 U FP
contains equivalent
fibrinogen to 10 U cryo
Post MTP: enter Clinical
Communication: MD to
Nurse: list all Blood
products transfused
during MTP.
√ 4 Units FP √ 1 dose Platelets
Pack may be customized upon request
DOSE
RBCs
SCM
Standard MTP Pack (Foundation Ratio)
General Guidelines for Lab Based Blood
Component Replacement in Adults
PRODUCT
There is NO order in
SCM to activate MTP.
Warm RBCs, Plasma using level 1 rapid infuser DO NOT WARM PLATELETS
Q30 Minutes
Hemostasis
& resolution of
coagulopathy?
Yes
No
Stop MTP
REPEAT CBC, INR, PTT
& fibrinogen
►STAT hand delivery of
* Notify TM & return any unused
blood asap
* Resume standard ordering
practices in SCM
Q1h→ Consider repeat ionized
Ca and K+
Clinical Team member
calls TM at 4-1367 for
another MTP pack.
samples is best
1 Massive Transfusion Definitions Replacement of 50% of blood volume in 3 hrs or blood loss >150 ml/minute or 4 units RBC in 4 hrs in setting of major bleeding or replacement of a blood volume in 24 hrs.
2 Dzik et al. Clinical review: Canadian National Advisory Committee on blood and Blood Products – Massive Transfusion Consensus Conference 2011: report of the panel. Critical Care 2011:15:242.
3 CRASH-2 trial collaborators (2010). 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, 376:23
4 Rossaint R. Management of bleeding following major trauma: an updated European guideline. Critical Care 2010;14:R52
CLS form# TSO1302
R20130416
COMMUNICATION IS VITAL.
CONTACT other team members/departments to
confirm MTP activation, sending of samples, or
receipt of box. Pack is to follow patient.
FAST SAMPLING IS KEY.
STAT hand delivery of samples by a clinical
team member is best (alt. for ED may use tube).
Alert Accessioning Dept of urgency of testing
(44066).
Above delivery of lab* samples facilitates
results in SCM in 25 minutes (*CBC, INR, PTT
and fibrinogen).
CONTENTS OF PACKS:
NO T&S: 6 U Group O RBCs : 2 U Group AB FP
: 1 dose of platelets (Rh of RBCs will depend on
sex of patient).
Current T&S (Known Blood Group): 6 U RBCs
: 4 U FP : 1 dose platelets. All products group
specific or matched.
AVOID WASTAGE: Use products effectively.
Packs can be customized. Consider transfused
totals and patient needs; inform TM of needs
when ordering packs.
4 units of FP and 10 units cryo contain
comparable fibrinogen levels; if FP transfusion is
continuing, cryo is rarely needed.
TM stocks some thawed plasma for
emergencies, but avoid wastage of ALL
products.
Do not warm or cool platelets.
Return unused blood/packs to TM ASAP.
ENSURE TRACKING OF PRODUCTS.
Clinical team must tally transfused totals and
record in chart and SCM (see Post MTP).
■ Reference 2 is a Canadian document
approved by the National Advisory
Committee.
■ Reference 4 is a comprehensive evidencebased European guideline on the
management of massive bleeding.