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Massive Transfusion for Trauma Protocol

Purpose

Hemorrhage is the leading cause of early death following traumatic injury. Protocol-driven transfusion strategies that approach a 1:1:1 ratio in patients who require massive transfusion improve patient survival, reduce hospital and ICU length of stay, decrease ventilator days, and ultimately reduce patient care costs.

These guidelines are meant to standardize the approach to resuscitation of an injured patient in hemorrhagic shock utilizing massive transfusion.

This guideline is a supplement to and is to be used in conjunction with theNebraska Medicine’s organizational policies "“Massive Transfusion/Severe Coagulopathy"Coagulopathy” (TX-36) and "“Guidelines for Management of Bleeding in Patients Receiving Anticoagulation"Anticoagulation” (MP 11). 

Background/Definitions

ThisMassive guidelinetransfusion standardizesmay be defined as transfusion in response to massive and uncontrolled hemorrhage resulting in any of the assessmentfollowing:

  • Replacement of coagulopathy including assessment and treatmenthalf of acidosis,a hypothermia,patient’s andtotal hypocalcemiablood volume in thea trauma4 patienthour population. 

    Definitions

      period
    1. MassiveReplacement Transfusionof Protocola (MTP):patient’s utilized when anticipated blood loss is greater than onetotal blood volume within 24 hours
      2. (weight
    2. Transfusion in kilograms x 70 mL),of >10 units packedof redPRBCs blood cells (PRBC) withinin 24 hours
    3. Specific pediatric parameters are more challenging to define and include transfusion of admission,>40mL/kg or >4 units PRBCPRBCs in 1a hour.short MTPperiod includesof componenttime. replacement (thawed plasma, apheresis platelets, and pre-pooled cryoprecipitate).
        • MTP pack 

        • Hemorrhage

      is
      4. the
    most common cause of death within the first hour of arrival to a trauma center. Blood product resuscitation, specifically massive transfusions, are often unplanned and require the processing and delivery of large amounts of blood products rapidly for a sustained period of time, significant preplanning and coordination between the blood bank, resuscitating unit (i.e. emergency department, operating room, intensive care unit) and pharmacy is required. The initiation of a massive transfusion protocol (MTP) outlines a standard process for the safe, rapid preparation and delivery of blood products and coagulation factors for the pediatric patient experiencing massive hemorrhage. Additionally, implementation of a standardized guideline may prevent the anticipated complications of massive transfusion including thrombocytopenia, coagulopathies, electrolyte and acid/base disturbances, hypothermia and transfusion reactions as well as utilize valuable blood components in a resourceful manner.

    At Nebraska Medicine, the massive transfusion protocol is divided into 3 categories based on the patient’s weight with each pack within that category containing the following blood product components.

    Weight

    MTP type

    Packed Red Blood Cells (PRBC)

    Thawed Plasma (FFP)

    Apheresis Platelets

    Pre-pooled Cryoprecipitatecryoprecipitate (cryo)
    Greater than

    Adult 50(> kg40 kg)

    6 (O pos)

    6 (A)

    1

    On pack #3 and every pack thereafter
    Less than

    Pediatric 50(10-40kg)

    kg

    6 (O pos)

    6 (A)a)

    1

    On pack #3 and every pack thereafter

    Neonate/Infant (less than <10 kg)

    1 (O neg, irradiated)

     

    1 (irradiated)

     
    1. Emergency

      Guideline ReleaseInclusion Blood:Criteria

      immediately

      Injured availablepatients with concern for massive or uncontrolled hemorrhage.

      Guideline Exclusion Criteria

      This is a guideline only. Individual circumstances need to be considered, as there may be times when it is appropriate to deviate from this guideline.

      Diagnostic Evaluation

      Injured patients should be assessed per ATLS guidelines paying close attention to circulation. Presence or history of hemodynamic instability, poor perfusion and external blood productsloss are red flags for hemorrhage. Signs of hemodynamic instability or poor perfusion may include altered mental status, pallor, delayed capillary refill, tachycardia, and hypotension. Hypotension is often a late sign of hypovolemic/hemorrhagic shock.

      Practice Recommendations for Management

      Initiation and Activation

      • The decision to activate MTP is a clinical decision made by the trauma or emergency medicine attending physician and should be strongly considered with one or more of the following criteria:
          • Persistent hemodynamic instability
          • Shock Index >1 (SI = HR/SBP)
          • Active bleeding requiring operation or angioembolization
          • Blood transfusion in which time does not permit compatibility testing (non-MTP or trauma situations)
              1. Emergency Department (ED) trauma bay kiosk refrigerator: 6 O-positive PRBCs, 2 O-negative PRBCs, 3 A thawed plasma
              2. Trauma operating room (OR) kiosk refrigerator: 6 O-positive PRBCs
              3. Blood bank: boxed blood (4 O-negative PRBCs) and limited quantity universally compatible PRBCs, thatwed plasma, platelets and cryo. 

            • Initiation of MTP

            Activation of the massive transfusion protocol is at the discretion of the Trauma AttendingBay

          • Adult patients (>40 kg)--Anticipated of transfusion of >10 units PRBC in 24 hrs or Emergency>4 Medicine physician,units in lieu1 hr.
          • Pediatric patients (≤40kg) -- Anticipated or actual use of the≥ trauma40 attending.mL/kg ThePRBCs attendingin should2 considerhours activationor replacement of MTPtotal if:blood

            volume
              (approximately ≥ 80 mL/kg) in 24 hrs
            1. Assessment of blood consumption (ABC) score is two≥2 or(adults moreonly):
                  • penetratingPenetrating mechanism of injury (1 pt)1pt)
                  • systolicSystolic blood pressure less than or equal to 90 mm Hg (1 pt)1pt)
                  • heartHeart rate greater than or equal to 120 (1 pt)1pt)
                  • positivePositive FAST exam (11pt) pt) 
    2. PersistentInitiation hemodynamicof instabilityMTP should not be delayed for lab results.
        • Universally compatible RBC (SBP<90)O despiteRh-negative) twoand thawed plasma may be given.
    3. Emergency release blood should be utilized as indicated until MTP blood products are available.
        • Whole blood is preferred in the initial resuscitation of hemorrhagic shock in patients age 13 and older. 4 units of whole blood (O positive) are available for trauma resuscitations in the emergency department (ED) and can be found in the ED trauma bay kiosk refrigerator pending inventory availability.
        • Emergency release blood is located in the following locations:
            • Emergency Department (ED) trauma bay kiosk refrigerators (2 kiosks located in T1 and T4) each containing 2 units O positive whole blood, 2 units O negative PRBC, 6 units O positive PRBCs, and 3 units A plasma
            • ShockBlood indexbank >1keeps (SI = HR/SBP)
            • Active bleeding requiring an operation or angioembolization
            • Anticipation of transfusing >10 units PRBC in 24 hours or >4 units PRBCO innegative 1PRBC, hour.12 units O positive PRBC, 12 units A plasma, 8 units platelets, and 25 units pre-pooled cryoglobulin (frozen).   

    4. To activate the MTP, the attending physician (or designee) will notify the Blood Bank via telephone (402-559-3639) that MTP is being activated and provide the following information:
        • Caller name and title
        • Caller location
        • Caller contact number
        • Ordering provider’s name
        • Patient’s name (may be the trauma name or real name)
        • Patient’s MRN
        • Category of MTP being activated (adult, pediatric, neonate/infant)
        • Patient’s weight (kg)

    Blood Product Administration and Transfusion Goals

      • Minimize crystalloid or colloid resuscitation to prevent dilutional coagulopathy. Instead,
        • begin early
      • Utilize emergency release blood productproducts infusion and initiateuntil MTP products are available.
      • Blood products are released in 1:1 ratios of whole units but will be administered based on abovethe triggers.clinical
        • status
      • Transfuseof plasma,the PRBC,patient and plateletsat inthe discretion of the attending physician.
          • Maintaining a ratio of 1:1:1 transfusion ration of PRBC to FFP to Platelets is recommended. (plasma:PRBC:platelet).Platelets Transfuseare pooled-packs thus one apheresis plateletplatelets should be transfused for every 6 units of PRBCPRBC/FFP with the exception of neonatal/infant MTP resuscitations where apheresis platelets serves as FFP and 6platelet unitscomponents). ofThese plasma.rations Referhelp to "Massiveavoid Transfusion/Severedilutional Coagulopathy" (TX-36) for childrencoagulopathy and infantthrombocytopenia specificand ratios.have been associated with decreased mortality.
      •  Pediatric Patients (≤40 kg), recommended volumes include:
          • PRBC – 20 mL/kg
          • FFP – 20 mL/kg
          • Apheresis Platelets – 5 mL/kg
          • Cryoprecipitate – 0.1 unit/kg
              • Consider cryoprecipitate if serum fibrinogen levels remain less than 150 mg/dL following FFP.
      • Massive transfusion products should be administered rapidly and warmed via a rapid infuser with the exception of platelets.platelets
          • For pediatric patients requiring smaller volumes, a “push-pull” system with 60mL syringe, stop-cock, and tubing may be utilized.
      • Initial rate of transfusion should restore perfusion,perfusion but allow permissive hypotension until bleeding has been controlled in the operating room or interventional radiologyradiology.
      • Blood product resuscitation should be based on clinical evidence of ongoing bleeding in addition to quantitative data, such as thromboelastography (TEG)ROTEM when available.
      • Utilization of the patient'patient’s own blood when safe (use ofi.e. cell saver, autotransfusion from chest tube, etc.)etc) also provides redailyreadily available warm, matched blood.

      Therapeutic Adjuncts in MTP

      Tranexamic Acid (TXA)

      • TXA is an antifibrinolytic used to treat coagulopathy. TXA should be initiated early in the coagulopathic cascade – within the first 3 hours of bleeding, in order to be effective.
      • TXA should be administered based on the evidence of shutdown of fibrinolysis or hyper-fibrinolysis on ROTEM and/or provider discretion.
      • Recommended dosing:
          • <12 years:
              • Loading dose of 15 mg/kg (max dose 1000mg) intravenous administered over 10 minutes
              • Maintenance infusion of 2mg/kg/hr intravenous for 8 hours (max dose 1000mg)

  • ≥12 years/Adult Dosing:
      • Loading dose of 1000 mg intravenous administered over 10 minutes
      • Maintenance infusion of 1000 mg intravenous over 8 hours

    • Calcium

    • The rapid rate of transfusion during MTP often exceeds the liver’s capacity to metabolize citrate, leading to severe hypocalcemia. Calcium is also required by several clotting factors for activation, stabilization of thrombus formation and contractility of myocardial and smooth muscle cells. Hypocalcemia can lead to coagulopathy, myocardial depression and vasodilation—all physiologic changes that complicate the management of hemorrhagic shock. Thus, adequate calcium repletion is an important component of MTP.
    •  Adults (>40 kg): 3g IV calcium chloride should be administered following completion of each MTP cooler.
    • Pediatric patients (≤40 kg): 20 mg/kg IV calcium chloride should be administered after every 2 rounds of PRBC/FFP

    Anticoagulant Reversal

    • Injured patients in hemorrhagic shock with pre-existing anticoagulant use should be reversed with the appropriate reversal agent. See “Guidelines for Management of Bleeding in Patients Receiving Anticoagulation” (MP 11) for additional details.

    ***Please utilize Pharmacy for any questions regarding dosage and use of therapeutic adjuncts.***

    Assessment of Coagulopathy and Transfusion Targets

      • Coagulopathy 
          • InitialRecommended initial lab testing:testing typeat andinitiation screen,of MTP include:
              • CBC, PT/PTT, INR, fibrinogen, ROTEM
          • Ongoing lab testing during MTP include:
              • CBC, PT/PTT, INR, fibrinogen, and TEG at initiation of MTP.
              • Ongoing lab testing: CBC, PT/PTT, INR, fibrinogen, and TEGROTEM every 4 hourshrs during MTP (or more frequently depending onas clinical situation)situation indicates.
          • ROTEM parameters
              • A5EXTEM <35 mm OR ML ≥ 5% (within 60 min) à give TXA
              • A5EXTEM <35 mm AND A5FIBTEM <9 mm à give cryoprecipitate
              • A5EXTEM <35 mm AND A5FIBTEM ≥9 mm à give platelets
              • CTEXTEM >80 s AND A5FIBTEM ≥9 mm  à Give PCC or plasma
              • CTINTEM > 240 s AND ( CTINTEM/CTHEPTEM) > 1.25 à give protamine, if suspected heparin activity or heparin like effects  
              • CTINTEM > 240 s AND ( CTINTEM/CTHEPTEM) < 1.25  à give plasma
      •  Acidosis 
          • Goal: Lactic Acid <2.0 2
          • Goal: Base deficitDeficit <4.04
          • Ongoing lab testing: Lactic acid and arterial blood gas (ABG) to obtainassess a acid-base deficitstatus every six6 hourshrs during MTP (or more frequently depending onas clinical situation)situation indicates.
      • Hypothermia
            • Goal: 36 degrees Celsius or warmer 
            • All trauma patients should undergo passive external rewarming including warmed blankets and increased ambient room temperature. temperature
            • Administer warm blood products.products
            • Continuously monitor utilizing a core temperature probe.
      • Hypocalcemia
            • Goal: Ionizedionized calcium (iCa) >1.0 mmol/L
            • Ongoing testing: iCa should be monitored at initiation of MTP and after completion of each MTP cooler.  
            • After completion of each MTP cooler, 3 grams of calcium chloride IV should be administered.
      • Hyperkalemia
            • Goal: Potassiumpotassium <5.05
            • Ongoing lab testing: Potassium every 6 hrshours during MTP (or more frequently depending onas clinical situation).situation
              • indicates.

    Therapeutic Adjuncts

    1. Tranexemic Acid (TXA)
        • Should be given within 3 hours of injury
        • Indications (to be ordered at discretion of trauma attending):
            • activation of massive transfusion protocol
            • adult trauma patients with severe hemorrhagic shock 
            • known fibrinolysis by TEG
        • Dosing: 1 gram IV over 10 minutes followed by 1 gram IV infusion over next 8 hours. 

        2. Discontinuation

      and
      2. Transition
    2. Anticoagulationto reversalGoal Directed
      1. Therapy

        • ThisRatio-driven guidelinemassive istransfusion amay supplementbe discontinued and transitioned to andgoal-directed is to be used in conjunction with the organizational policies "Massive Transfusion/Severe Coagulopathy" (TX-36) and "Guidelines for Management of Bleeding in Patients Receiving Anticoagulation." (MP 11) 

    Termination and Endpoints for MTP

    Termination and endpoints should betransfusion based uponon anatomiclaboratory andfindings physiologic criteria. 

    1.  Whenif surgical bleeding has been controlled or there is radiographic and physiologic evidence of bleeding control after embolization,embolization.
    2. MTP canmay also be terminated.discontinued Resuscitationwhen canthere thenis berecognition basedthat on specific, ongoing laboratory testing such as thromboelastography (TEG). 
    3. Whenfurther resuscitation is futile,futile. MTP can be terminated. 
    4. ResuscitationSuggested ofvalues anyfor kindGoal (MTPDirected andTherapy: goal directed based on labs) can be terminated if:
          • noHemoglobin active≥ surgical bleeding10g/dL
          • hemoglobinPlatelets greater than or equal to 10, stop PRBC transfusion>150,000/mcL
          • prothrombinPT <18 seconds
          • PTT < 35 seconds
          • INR <1.5
          • Fibrinogen >180
          • ROTEM
              • Clotting time (PT)CT) – CTIN<18215 seconds,and stop plasma transfusionCTEX<75
              • partialAmplitude thromboplastin5 timemin after CT (PTT) <35 seconds, stop plasma transfusionA5)—A5IN,EX>33
              • InternationalAmplitude Normalized10 Ratiomin after CT (INR) <1.5, stop plasma transfusionA10)—A10IN,EX>45
              • plateletMaximum countclot firmness (MCF)—MCFIN,EX>15056 xand 109, stop platelet transfusionMCFFIB>5
              • fibrinogenMaximum levelLysis >180, stop cryo transfusion(ML)—MLIN,EX,FIB<7%
              • R value <9 on TEG, stop plasma transfusion
              • K-time <4 minutes on TEG, stop plasma and/or cryo transfusion
              • alpha-angle >60 degrees, stop cryo and/or plasma transfusion
              • mA>55 mm, stop platelet transfusion
              • LY30 <7.5%, stop anti-fibrinolytics

    PerformanceOutcome ImprovementMeasures and Guideline Adherance

    All trauma massive transfusion activations will be monitored through the Traumatrauma Performanceperformance Improvementimprovement Process.(PI) process. Specific indicators that will be monitored/assessed include:

    1. timeTime from initiatinginitiation of MTP to infusion of the first unit of PRBCs
    2. timeTime from initiatinginitiation of MTP to infusion of the first unit of plasma
    3. overallOverall ratioration of blood product transfusion and at two2 hours
    4. totalTotal blood products used from MTP activation to 24 hours
    5. notifying theNotifying blood bank within one1 hour of MTP termination
    6. bloodUse productof wastagetherapeutic ratesadjuncts
    7. useComplications of adjuncts
    8. complications
      • transfusionTX36 relatedMassive adverseTransfusion/Severe reactions
      • coagulopathy
      • thrombotic complications
      • acute respiratory distress syndromeCoagulopathy 
      • over-transfusion
        • MP
      • mortality11 Guidelines for Management of Bleeding in Patients Receiving Anticoagulation 

      Key Contributors

      • Emily Cantrell, MD | Division of Acute Care Surgery, Faculty | Principle Author
  • Abby Josef, MD | Division of Acute Care Surgery, Faculty | Author

    • References

    1.  American College of Surgeons Trauma Quality Improvement Program. (2015) ACS TQIP Massive Transfusion in Trauma Guidelines. Retrieved from https://www.transfusion_guildelines.pdf (facs.org/~/media/files%20programs/trauma/tqip/massive%20guideline.ashxorg) 
    2. American College of Surgeons Advanced Trauma Life Support, 10th10th Ed. 2018. 
    3. Callcut RA, Cotton B, Mskat P, Fox EE, Wade CE, Holcomb JB, Robinson RH. (2013) Defining when to initiate massive transfusion (MT): A validation study of individual massive transfusion triggers in PROMMTT patients. J Trauma Acute Care Surg. 74(1), 59-67. 
    4. Schroll R, Swift D, Tatum D, Courch S, Heaney JB, Llado-Farulla M, Zucker S, Gill F, Brown G, Buffin N, Duchesne J. Accuracy of shock index versus ABC score to predict need for massive transfusion in trauma patients. Injury.Injury. 49(1), 15-19.
    5. NaplitanoNapolitano LM, Cohen MJ, Cotton BA, Schreiber MA, Moore EE (2013). Tranexamic acid in trauma: How we should we useus it? J Trauma Acute Care Surg,. 74(6), 1575-1586. 
    6. Nunez TC, VoskresenskyVoskrensensky IV, Dossett LA, ShinallShinal R, Dutton WD, CottenCotton BA. (2009) Early prediction of massive transfusion in trauma: simpleSimple as ABC (assessment of blood consumption)? J Trauma: Injury, Infection, and Critical Care. 66, 346-352. 
    7. Panteli M, Pountos I, Giannoudis PVPV. (2016). Pharmacological adjuncts to stop bleeding: optionsOptions and effectiveness. Eur J Trauma and Em Surg. 42, 303-310.
    8. Stettler GR, Moore EE, Nunns GR, Chandler J, Peltz E, Silliman CC, Banerjee A, Sauaia A. (2018) Rotational thromboelastometry thresholds for patients at risk for massive transfusion. J Surg Res. 228: 154-159.
    9. Chidester SJ, Williams N, Wang W, Groner JI. (2012) A pediatric massive transfusion protocol. J Trauma Acute Care Surg. 73(5), 1273-1277.
    10. Eckert MJ, Wertin TM, Tyner SD, Nelson DW, Martin MJ. (2014) Tranexamic acid administration to pediatric trauma patients in a combat setting: The pediatric trauma and tranexamic acid study (PED-TRAX). J Trauma Acute Care Surg. 77(6), 852-858.
    11. Neff LP, Cannon JW, Morrison JJ, Edwards MJ, Spinella PC, Borgman MA. (2015) clearly defining pediatric massive transfusion: Cutting through the fog and friction with combat data. J Trauma Acute Care Surg. 78(1), 22-29.

    Last updated:

    August,May, 20192024

    TX36 Massive Transfusion/Severe Coagulopathy 

    MP 11 Guidelines for Management of Bleeding in Patients Receiving Anticoagulation 

     

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