LEEDS TEACHING HOSPITALS TRUST
eClinical Guidelines Template
Transfusion in massive haemorrhage in trauma (Adults)
Guideline Detail
Ownership Jonathan Jones, Consultant in Emergency Medicine (contact for
review)
Fran Hartley, Transfusion Practitioner
Publication date
October 2010 (updated version: Oct 2013)
Next Review date October 2016
Summary
For adult patients with massive haemorrhage as a result of traumatic injury better
outcomes are achieved by the use of early, aggressive blood component
resuscitation.
Aims
To improve outcome in victims of major trauma through the use of appropriate
and timely blood component transfusion.
To minimise wastage of blood components.
Objectives
To provide clear guidance to clinical teams managing victims of major trauma on
what to transfuse, when to give it and how to request it.
Background
An accumulating body of evidence and expert opinion supports earlier use of
blood components in the resuscitation of patients with massive haemorrhage as
a result of traumatic injury. Packed red blood cells and fresh frozen plasma (FFP)
should be given in a ratio of 2:1 (or less). Platelets and cryoprecipitate are also
necessary following large volume blood product resuscitation. It is vital that
scarce blood component resources are used appropriately.
This document must be used in conjunction with the LTHT Policy on Safer
Transfusion Procedures,
http://nww.lhp.leedsth.nhs.uk/common/guidelines/detail.aspx?ID=1864
and the Policy for the use of written informed consent for transfusion of blood and
blood components
http://nww.lhp.leedsth.nhs.uk/common/guidelines/detail.aspx?ID=1217
and the Guideline for Generic Management of Massive Haemorrhage,
http://nww.lhp.leedsth.nhs.uk/common/guidelines/detail.aspx?ID=2275 (adults)
Diagnosis
The massive haemorrhage in trauma protocol should be activated when:
Systolic BP < 90mmHg following initial crystalloid resuscitation (no more than 2
litres) AND
There is suspected active haemorrhage AND
A consultant with experience in the management of major trauma authorises its
use.
Investigation
This guideline does not cover the investigation of the source of the
bleeding but assumes that all appropriate measures to identify and stop the
bleeding are ongoing.
For details on appropriate investigations in the management of massive
haemorrhage see the above referenced policies.
Treatment / Management
This guideline does not cover the management of bleeding in trauma per se but
rather the appropriate use of blood components for the resuscitation of victims of
major trauma. The guideline assumes that all necessary measures to identify and
control bleeding sites are ongoing. Furthermore effort must be directed at
preventing hypothermia by the use of fluid warmers and external warming
devices (eg Bair hugger).
To improve confidence and maintain best practice when managing massive
haemorrhage, it is strongly recommended that teams hold regular (at least
annually) ‘dry-runs’ / ‘drills’ to practice individual team member roles in a massive
haemorrhage scenario and to ensure a cohesive team approach in managing
patient
A successful outcome requires prompt action and good communication between
clinical specialities, diagnostic laboratories, blood bank staff and the local blood
centre. Correctly labelled blood samples, early surgical involvement and an
emphasis on acute haemorrhage control are key to patient survival.
A member of the clinical team should be nominated to act as co-ordinator
responsible for overall organisation, liaison, communication and
documentation. This is a critical role for a designated member of the
permanent clinical staff. A checklist with the recommended order of
actions for the co-ordinator to follow can be found in Appendix 1.
1. Call blood bank (x23398). Give patient details (including whether more
than 1 casualty). State: “This is a massive haemorrhage” & request
“Massive Transfusion Pack 1”. Avoid any further calls to blood bank unless
the situation changes.
2. Ensure CORRECTLY LABELLED patient ID wristband is in place
(preferably, detailing the patient’s NHS number as the primary identifier.
No wristband, no transfusion).
3. Ensure CORRECTLY LABELLED transfusion sample taken. This should
be taken to blood bank on A-Floor of Jubilee Wing by hand as this is the
fastest route and allows confirmation that the sample is acceptable. DO
NOT use the point to point airtube.
4. At the same time, take samples for FBC, clotting screen and U&E and
send to Blood Sciences Lab in Old Medical School by point to point airtube
5. While awaiting the massive transfusion ‘pack’, use Emergency O -ve blood
from the Emergency Department supply if immediate red cell transfusion is
essential. Aim for a balanced resuscitation approach if no significant head
injury. Once the decision to activate the massive transfusion in trauma
protocol has been taken aim to avoid using additional crystalloid or colloid.
NB: It is recommended to use A&E staff to run/collect blood components during
an emergency and not to rely on the general portering service
6. Massive transfusion pack1 consists of 8 units red cells and 4 units Fresh
Frozen Plasma (FFP). Give red cells and FFP in a 2:1 ratio. Transfuse
FFP alongside red cells using separate IV access.
7. After 4 units red cells have been given the senior clinician must decide
whether the second massive transfusion pack is required. If it is contact
blood bank and request “Massive Transfusion Pack 2”.
8. When massive transfusion pack 1 is given administer intravenous
tranexamic acid 1g over ten minutes (so long as it’s within 3 hours of the
injury) followed by another 1g over the next 8 hours.
9. Massive transfusion pack 2 consists of 8 red cells, 4 units FFP, I adult
dose of platelets and 2 pools of cryoprecipitate. If any of the red cells of
massive transfusion pack 2 are given the adult dose of platelets and the
cryoprecipitate must also be given assuming the patient’s fluid status will
allow for this. Do not wait for blood results but be guided by the clinical
assessment of the ongoing need for fluid resuscitation.
10. Following the administration of platelets, cryoprecipitate and the majority
of the red cells and FFP ensure a repeat clotting screen and FBC are sent
to haematology. This will guide further blood component administration.
11. Further blood components should be requested as needed guided by
blood results and in liaison with doctor on call for haematology.
12. Any unused blood components MUST be returned to blood bank
immediately
13. All red cells received in Resus must be checked into the blood fridge. Or, if
blood arrives in a cool box it should be kept in the cool box in which it
arrives for up to the maximum length of time stated on the transport slip.
Each blood unit should be removed and used one at a time, between each
removal ensure the lid is securely positioned on the cool box at all times.
Platelets MUST NOT be cooled.
14. All blood components must be recorded on a transfusion prescription and
fated using the Autofate system or by signing and sending the manila tag
attached to each blood component.
15. Patients on warfarin with significant bleeding from trauma should be given
25 international units / kg of intravenous Prothrombin Concentrate
Complex (PCC) i.e. Beriplex/Octaplex (requested on the PCC request
form - see: http://lthweb/sites/hospital-transfusion-team/how-to-orderblood-and-blood-products/Product%20Order%20form%202010.pdf)
assuming they do not have an absolute contraindication to reversal. Do
not wait for an INR result before giving the Octaplex. Remember that PCC
has a short half life (4-6 hours). If longer term reversal is indicated give
5mg (slow bolus) intravenous vitamin K as well. For further information
see: http://nww.lhp.leedsth.nhs.uk/common/guidelines/detail.aspx?ID=550
16. Because of the large citrate load from anticoagulated blood components,
ionised hypocalcaemia may occur, especially if there is liver synthetic
dysfunction. This may interfere with coagulation and have other adverse
metabolic consequences. Ionised calcium can be reliably measured on a
blood gas machine. This may be corrected by intravenous infusion of
calcium chloride. A dose of 10ml 10% calcium chloride has been
recommended, alternatively 2.5 to 5.0 mmol in divided doses over 10
minutes followed by repeat of the assay.
17. All activations of the massive transfusion protocol in trauma must be
reviewed as part of the departmental trauma clinical governance
procedure.
Provenance:
Jonathan Jones, Consultant in Emergency Medicine
Fran Hartley, Transfusion Practitioner
Clinical condition: Major trauma
Target patient group: Victims of major trauma
Target professional group (clinical competence): Medical / Nursing / Laboratory
staff involved in the management of major trauma
Evidence Bases:
Crash 2 trial collaborators.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
DOI:10.1016/S01406736(10)60835-5
Johansson PI, Stensballe J. Hemostatic resuscitation for massive bleeding: the
paradigm of plasma and platelets - a review of the current literature. Transfusion
2010 v50 p701-710
National Patient Safety Agency: Rapid Response Report, NPSA/ 2010/RRR 017
Shaz BH, Dente CJ, Nicholas J et al. Increased number of coagulation products
in relationship to red blood cell products transfused improves mortality in trauma
patients. Transfusion 2010 v50 p493-500
Shaz BH, Dente CJ, Harris RS et al. Transfusion management of trauma
patients. Anesth Analg 2009;108:1760-8
British Committee for Standards in Haematology. Guidelines on the management
of massive blood loss. Brit J Haematol 2006;135:634-641
(www.bcshguidelines.com).
All uses of this guideline will be audited internally and by the Hospital Transfusion
Team.
Evidence level:
B. Robust experimental or observational studies
De-briefing
It is a requirement of the NPSA Alert RRR 017 that clinical areas involved hold a
‘de-brief’ after each massive haemorrhage case to establish any learning points
and/or if any changes in practice are required to improve the outcome in future
massive haemorrhage situations. The de-brief should be initiated by the
Consultant in charge and/or the Hospital Transfusion Team. Feedback on any
lessons learned will be circulated to relevant stakeholders by the Consultant in
charge and/or the Hospital Transfusion Team.
The de-brief group should consist of all key stakeholders including representation
from the Hospital Transfusion Team and Transfusion lab to enable a full and
robust analysis of the approach to the massive haemorrhage case.
Transfusion Management of Massive Trauma Haemorrhage
Aim to transfuse to a ratio of 2:1 (i.e. 8 units Red Cells to 4 units FFP)
The massive haemorrhage in trauma protocol should be activated when: Systolic BP < 90mmHg following initial crystalloid resuscitation (no
more than 2 litres) AND there is suspected active haemorrhage AND A consultant with experience in the management of major trauma
authorises its use.
1.
Resuscitation: Arrest bleeding & Restore circulating volume





Insert two wide-bore peripheral cannulae
Give adequate volumes of warmed crystalloids, colloid and red cells
Early invasive monitoring
Use blood warmer: level 1 rapid infuser and warm air blanket
Frequent arterial blood gases including haematocrit
2.
Contact Key Personnel



Consultant clinician
Consultant anaesthetist on-call
Transfusion Laboratory. State: ‘Massive
Haemorrhage’ and request appropriate ‘massive
transfusion’ pack (tel. LGI: 23398)
3.

Nominate a Team ‘Runner’ to collect blood
components or,

LGI blood bank will automatically request porters to
deliver blood components
Perform following Investigations






FBC and Coagulation Screen (PT, APTT, fibrinogen) (Do NOT use a gas analyser to test Hb levels)
Group & crossmatch
Thromboelastography (TEG), if available
Biochemistry (U & E’s, LFT’s)
Repeat ABGs to monitor acidosis
Repeat FBC, PT, APTT, fibrinogen after blood component replacement
4. TRANSFUSION:
Request “massive transfusion pack 1” (8 RBC & 4 FFP)
(Use O negative (from emergency stock) only in extreme emergency)
Administer Massive Transfusion Pack Red Cells

Transfuse red cells as soon as available

Keep the patient warm
Administer Fresh Frozen Plasma


Transfuse FFP as soon as it is available (average adult dose is 4 units) – administer alongside red cells using separate IV access
Allow at least 40 minutes thawing & delivery time
Administer Tranexamic Acid I.V. 1gram if within 3 hours of the injury, followed by another I.V. 1gram over the next 8 hours
If bleeding persists; request “massive transfusion pack 2” (8 RBC, 4 FFP, 2 cryo & 1 platelets)
Administer Red Cells & FFP as before
Administer Cryoprecipitate

Transfuse cryoprecipitate as soon as it is available (2 x 5 donation pools (2 packs))

Allow at least 40 minutes thawing & delivery time
Administer Platelets


Transfuse platelets (1adult therapeutic doses)
Allow time for delivery from National Blood Centre – up to 90 minutes
*Depending on repeat FBC/clotting - continue requesting further massive transfusion pack 2 until bleeding stops*
When bleeding is controlled repeat FBC & clotting – administer further components if:



Platelets < 80 x 109/l – administer 1 adult dose platelets
Fibrinogen < 1.0 g/l – administer 2 pooled doses cryoprecipitate
APTT or PT ratio > 1.5 x normal – administer 4 units FFP
Appendix 1:
Massive Haemorrhage Co-ordinator Prompt / Checklist
Coordinator: When instructed by the clinician that a massive haemorrhage is taking place, please follow
checklist of tasks below to undertake in order – when completed: sign & time
Patient’s Full Name:…………………………………………………………………………………………………………
Date of Birth:………………………………………………………………………………………………………………….
ID Number:…………………………………………………………………………………………………………………….
Today’s Date:…………………….……Time episode started………….……………Ended………………………..….
Your Name……………………………………………………………………………………………………………………..
Contact Key Personnel
Personnel
Contact Number
Done
Time
Signature
Consultant Clinician
Consultant Anaesthetist
Senior resident doctor
Blood Bank: Request: ‘Massive Transfusion Pack 1’
23398 (LGI)
(8 units blood and 4 units FFP will be delivered: transfuse
concomitantly)
Nominate a team ‘runner’ to collect blood.
Name:
Call haematology for full blood count / clotting results
Blood Bank: Request: ‘Massive Transfusion Pack 2’
(8 red cells, 4 FFP, , 2 cryoprecipitate & 1 platelets will be delivered)
Telephone Biochemistry for U & E’s, LFT results
Repeat FBC, PT, APTT, fibrinogen after blood component
replacement. Record TEG.
ALL blood components fated?:
Return all unused blood components immediately
Time:
FBC Results
Time:
U&E / LFT Results
Upon completion, file this checklist in the patient’s case notes.
Time:
Clotting results
Leeds Teaching Hospitals NHS Trust Aug 2013
Massive Transfusion & Blood Bank Communication
N.B. Aim to transfuse to a ratio of 2:1 (i.e. 8 units Red Cells to 4 units FFP)
TELEPHONE:
TELEPHONE:
- Clinician in charge
- Duty Anaesthetist
- BLOOD BANK (see next box)
- Transfusion Consultant } as appropriate
- CT Radiographer
}
- PORTERS
and explain the situation and its urgency
ADMINISTER TRANEXAMIC
ACID
BLOOD BANK (23398 LGI),
& tell them:
“This is a massive
haemorrhage”
Give them the patient’s:
- Full Name
- ID (NHS) / A&E No.
- Date of birth & sex
State which massive transfusion
pack is being requested
Where the blood is to be sent
Name & contact no. for doctor in
charge
Blood samples:
- Crossmatch
- FBC & coagulation screen
HAND DELIVER SAMPLES TO LAB
-
Useful Telephone No.
Blood Bank
23398
Haematology
22412
Duty
Consultants /
Contact via
CT
switchboard
Radiographer
Porters
22622
IV 1gram within 3 hours of injury,
followed by a further IV 1gram over
the next 8 hours
Request
Massive Transfusion
Pack
1
If immediate
transfusion is
required, use:
Use emergency
O negative red
cells in satellite
(local) blood
fridge
Send patient
sample &
request form
urgently to blood
bank BEFORE
administering
O negative
Or
Use emergency
O negative red
cells from
blood bank
Send patient
sample &
request form
urgently to blood
bank BEFORE
administering
O negative
Send patient
sample &
request form
urgently to
blood bank as
well as a
telephone
request
If no response to
pack 1,
telephone blood
bank and
request
Pack 1
contains:
Further 8 Red
Cells &
4 FFP
8 Red Cells
4 FFP
- transfuse
concomitantly
Administer
concomitant IV
1g Tranexamic
Acid
O negative red cells are usually in very short
supply
A sample should be sent to the blood bank
ASAP to allow conversion to group-specific
blood
After O negative has been removed from
designated fridges, inform Blood Bank as
soon as possible to enable stocks to be
replaced
If bleeding continues
Request
Massive Transfusion
Pack
2
If bleeding persists:
Consider:
TEG results
FBC/clotting
results
Clinical picture
Pack 2
contains:
Also:
2 pooled packs
Cryoprecipitate
1 adult dose
Platelets
REMEMBER:
REMEMBER:
It takes up to 40
minutes for FFP
to thaw plus
delivery time
Platelets may
need to be
delivered from
NBS (Seacroft)
& could take up
to 90 minutes
REMEMBER: in
surgical patients
intra operative
cell salvage may
be of great
benefit
If bleeding
continues
uncontrolled,
consider
recombinant
factor VIIa
(discuss with
Haematologist)
NB: use
appropriate
order form
Remember to call for porters at the beginning of the emergency you may need to consider nominating a departmental member of staff to act as
‘runner’.
Or, LGI Blood bank will automatically arrange for porters to collect/deliver urgent blood components
Prompt communication is vital to patient outcome during massive blood loss. The choice of wording is key to a speedy delivery of blood
and its components, try to avoid using ‘as soon as possible’ which can lead to ambiguity. If you require blood components immediately you
will need to request them ‘IMMEDIATELY’.