Hemorrhage and transfusion

Massive Hemorrhage Algorithm

Activating the massive transfusion protocol

Reviewed by Alex G, BSN, RN, CEN, CCRN, CMC, NREMT-P · From the Reference tab of the app

Each step lists what to do, then the choices that lead on. In the app the algorithm is tapped through one decision at a time.

1 Should you activate the MTP?

Ongoing major bleeding with shock: SBP under 90, HR over 120, or ABC score 2 or more (penetrating, SBP 90 or less, HR 120 or more, positive FAST)
Anticipating 4 or more units of red cells in an hour, or 10 in 24 hours

Yes: activate → step 2

2 Balanced resuscitation

Plasma, platelets and red cells 1:1:1 (or whole blood)
Tranexamic acid 1 g IV within 3 hours of injury, then 1 g over 8 hours
Limit crystalloid; warm every product (rapid infuser)
Permissive hypotension (SBP 80–90) until bleeding is controlled, unless brain injury

Next: control the bleeding → step 3

3 Stop the bleeding

Direct pressure, tourniquet, pelvic binder
Surgery, interventional radiology or endoscopy as the source dictates
Reverse anticoagulants (PCC, idarucizumab, protamine)

Next: monitor and correct → step 4

4 Monitor every 30–60 minutes

Hgb, platelets, INR, fibrinogen, or viscoelastic testing (TEG/ROTEM) to guide products
Fibrinogen under 150–200 mg/dL: cryoprecipitate
Ionized calcium: keep over 1.1 mmol/L; give calcium with every few units (citrate)
Potassium, pH, lactate and temperature (keep over 36 °C)

Bleeding controlled → step 5

5 Deactivate the protocol

Tell the blood bank so unused products return
Switch to lab-guided transfusion (Hgb 7, platelets 50 if bleeding)
Watch for TACO, TRALI and hyperkalemia

End of this path.

Drugs in this algorithm

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Postpartum Hemorrhage

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