TRAUMA SERVICE CHAPTER
POLICY AND PROCEDURE
Standards of
MANUAL
Care
SUBJECT: Massive Transfusion Guideline (60021)
POLICY
Massive Transfusion is initiated in order to prevent complications associated with large blood volume
replacements. It is indicated for patients experiencing ongoing massive bleeding (5 or more units of PRBC within
2-3 hours) and/or anticipation of such.
EQUIPMENT
Blood transfusion administration sets, fluid warmer and rapid infusion systems.
PURPOSE:
To provide rapid restoration of intravascular blood volume, maintain oxygen carrying capacity of the blood and
maintain coagulability of blood in the presence of acute massive blood loss.
GUIDELINES
1. Initiation of the Massive Transfusion
Guideline (MTG)
a) Any attending staff physician may request
implementation of the MTG.
b) The Attending physician or his/her
designee will be responsible for notifying
the Blood Bank of the need to implement
the MTG. The Attending physician or
his/her designee will utilize the phrase
“Initiate the Massive Transfusion
Guideline as ordered by Dr. (Attending).”
c) Simultaneously (or as soon thereafter), a
blood sample will be drawn and two (2)
large, purple-top tubes sent to the lab for
type and crossmatch.
PERTINENT DATA
All units not used immediately, will “travel” in the
designated cooler with the patient during transfer (i.e.
from the Emergency Department to MOR, CVOR, etc.)
For Level 1 Trauma patients, the Chief or Senior
Surgical Resident, the Emergency Department primary
Trauma Nurse or the Certified Registered Nurse
Anesthetist (CRNA) may request implementation of the
MTG, following consultation with the Attending
physician.
Call the Blood Bank at 22412.
Type specific blood will be issued only after blood
typing has been completed on two (2) samples collected
at different times.
d) Blood Bank staff will notify the
pathologist on call.
ISSUED BY:
Trauma/Surgical Critical Care
EFFECTIVE DATE:
SUPERSEDES EFFECTIVE DATE: 10/19/1999, 10/2000
APPROVED BY:
Trauma Physician Performance Improvement Committee,
Trauma Medical Committee, Practice Council
PAGE:
Page 1 of 5
TRAUMA SERVICE CHAPTER
POLICY AND PROCEDURE
Standards of
MANUAL
Care
SUBJECT: Massive Transfusion Guideline (60021)
2. Following the request to implement the MTG,
the Blood Bank will:
a) Set up a Massive Transfusion “Pack”
which will consist of:
i. 6 units of packed cells (PRBCs)
ii. 6 units fresh frozen plasma (FFP)
iii. 1 apheresis platelet
b) The Blood Bank will make every effort to
have one pack in reserve during the course
of the massive transfusion.
c) Pack will continue to be set up and
available in the Blood Bank until an order
to discontinue such has been received by
the attending physician or his/her
designee.
3. Notification and Transportation of Products
a) The Blood Bank will notify the treatment
area when the first massive transfusion
pack is ready
b) Product transport will be the responsibility
of the treatment area
c) Products will be transported in appropriate
delivery containers provided by the Blood
Bank. Blood can be sent to Main OR,
CVOR, CVICU and NSICU via the
pneumatic tube system. Main OR &
CVOR have their own coolers to place the
products in.
Treatment areas should always return the
containers when empty to the Blood Bank
when applicable.
4. Responsibilities of the Transfusionist (RN,
Whenever possible, only type specific blood products
should be released. In an emergent situation however, if
the physician or his/her designee determines that it is in
the best interest of the patient to continue to receive uncrossmatched blood products, applicable components of
the first pack may be released as such.
Turn-around time for the set up of a pack takes
approximately 30 minutes.
No further notification will be performed by the Blood
Bank since they will attempt to keep one pack in reserve
at all times, unless there is a problem or delay in pack
availability.
ISSUED BY:
Trauma/Surgical Critical Care
EFFECTIVE DATE:
SUPERSEDES EFFECTIVE DATE: 10/19/1999, 10/2000
APPROVED BY:
Trauma Physician Performance Improvement Committee,
Trauma Medical Committee, Practice Council
PAGE:
Page 2 of 5
TRAUMA SERVICE CHAPTER
POLICY AND PROCEDURE
Standards of
MANUAL
Care
SUBJECT: Massive Transfusion Guideline (60021)
CRNA, or Anesthesiologist):
a) The Transfusionist or his/her designee
will provide the Blood Bank with
appropriate patient identification.
b. The Massive Transfusion Pack will be
available every 30 minutes and will be
administered by the Transfusionist as
indicated by:
i) Patient clinical status
ii) Coagulation profile
iii) Physician order
c) All packed cells will be administered and
warmed via the appropriate method to
maintain normothermia.
d) Record all fluid infused (crystalloid /
colloids), all blood and blood products
given and all output on the appropriate
flow sheets.
e) Monitor and document vital signs
including temperature according to blood
administration policy and minimally every
30 minutes.
f) Transfusionist or his/her designee will be
responsible for drawing necessary blood
samples for all labs. All labs will be
drawn in pediatric tubes. While in the ED
consider the use of the iStat for available
laboratory tests.
i) Initial Labs:
(1) ABG or Shock Profile
(2) CBC
(3) BMP
(4) Coagulation Screen
ii) Labs every 30 minutes
(1) Shock Profile
A request form with patient identification stickers is
required when requesting a transfusion pack.
Shock Profile results include arterial blood gas plus
whole blood sodium, potassium, chloride, glucose,
lactate, and ionized calcium.
Basic Metabolic Panel (BMP) results include: sodium,
potassium, chloride, carbon dioxide, anion gap,
creatinine, BUN, glucose, and calcium.
Complete Blood Count (CBC) results include: WBC,
RBC, Hgb, Hct, MVC, MCH, MCHC, RDW, and PLT.
Coagulation Screen includes: PT, aPTT, INR, Platelet
count and Fibrinogen assay.
ISSUED BY:
Trauma/Surgical Critical Care
EFFECTIVE DATE:
SUPERSEDES EFFECTIVE DATE: 10/19/1999, 10/2000
APPROVED BY:
Trauma Physician Performance Improvement Committee,
Trauma Medical Committee, Practice Council
PAGE:
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TRAUMA SERVICE CHAPTER
POLICY AND PROCEDURE
Standards of
MANUAL
Care
SUBJECT: Massive Transfusion Guideline (60021)
(2) Coagulation Screen
g) The Transfusionist will consult with the
Guidelines:
Attending physician, Anesthesiologist,
 If hemoglobin <7, transfuse PRBC (consider
and/or the Pathologist to further determine
physiologic status, such as: if underlying CAD –
transfusion needs.
consider transfusion if Hgb <10)
i) PRBCs: based on hemoglobin and
 If INR >1.5, transfuse 4 units FFP; repeat until
hematocrit
INR controlled
ii) FFP: for prolonged PTT
 If platelet count <50, transfuse one apheresis
iii) Platelets: administer single donor
platelet unit to increase platelets by 25 – 50K
platelet to maintain coagulation.
(maintain between 50 – 100K)
iv) Cryoprecipitate : based on Fibrinogen
 If fibrinogen <100 mg/dL, transfuse 10 units of
level
cryoprecipitate. If fibrinogen <50 mg/dL,
transfuse 20 units of cryoprecipitate.
5. The Attending physician or his/her designee
will order cryoprecipitate, Factor rVIIa, and
FFP as indicated by coagulation tests.
The pathologist on call will be available for consultation.
Guidelines:
 Transfuse 10 units cryoprecipitate if fibrinogen
<100 mg/dL; 20 units if fibrinogen <50 mg/dL
 Administer Factor rVIIa (90 ug/Kg body weight)
if:
a) 2 massive transfusion packs have been
given
b) surgical control of bleeding is in progress
c) hypothermia (Temp < 36.5C) and acidosis
(pH < 7.2) have been corrected/addressed
d) PTT >60 and INR >2.0
e) Surgeon determines that life threatening
coagulopathic bleeding is present.
6. Discontinuation of MTG
a) The MTG may be discontinued by the
attending physician ONLY.
b) The Transfusionist will continue to
evaluate need for blood and blood
If no blood products have been issued for 90 minutes the
blood bank may contact the transfusionist to determine if
ISSUED BY:
Trauma/Surgical Critical Care
EFFECTIVE DATE:
SUPERSEDES EFFECTIVE DATE: 10/19/1999, 10/2000
APPROVED BY:
Trauma Physician Performance Improvement Committee,
Trauma Medical Committee, Practice Council
PAGE:
Page 4 of 5
TRAUMA SERVICE CHAPTER
POLICY AND PROCEDURE
Standards of
MANUAL
Care
SUBJECT: Massive Transfusion Guideline (60021)
products based on lab data and patient
the MTG needs to be continued.
clinical status. Blood and blood products
will be administered based upon physician
written or verbal order. If bleeding is
< 500 ml/hour the Attending physician
will be notified.
IN COLLABORATION WITH:
Trauma/Surgical Critical Care Service, Blood Bank, Operating Room, Nursing, Cardiovascular Surgery
REFERENCES
Malone, D. L., Hess, J. R. & Fingerhut, A. (2006). Massive transfusion practices around the globe and a suggestion
for a common massive transfusion protocol. The Journal of Trauma Injury, Infection, and Critical Care,
60(6), p. S91-S96.
Spahn, D. R. & Rossaint, R. (2005). Coagulopathy and blood component transfusion in trauma. British Journal of
Anaesthesia, 95(2), p. 130-139.
Stainsby, D., MacLennan, S. & Hamilton, P. J. (2000). Management of massive blood loss: A template guideline.
British Journal of Anaesthesia, 85(3), p. 487-491.
REPLACES PREVIOUS DOCUMENTS
Trauma Service Policy and Procedure #60021
ISSUED BY:
Trauma/Surgical Critical Care
EFFECTIVE DATE:
SUPERSEDES EFFECTIVE DATE: 10/19/1999, 10/2000
APPROVED BY:
Trauma Physician Performance Improvement Committee,
Trauma Medical Committee, Practice Council
PAGE:
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