It describes indications protocol and complications in detail

1. Massive Transfusion
Dr P K Maharana,
Department of Anesthesiology,
KIMS, BHUBANESWAR.

2. Introduction
Severe traumatic injury continues to present challenges to healthcare systems
around the world.
Post-traumatic bleeding remains a leading cause of potentially preventable
death among injured patients.
Worldwide 5 million patients die due to trauma or trauma-related
complications each year.
Deaths by exsanguination in trauma are preventable with hemorrhage control
and resuscitation with allogeneic blood products (ABPs).

3. Definitions
 Various definitions of massive blood transfusion (MBT) have been
published in the medical literature such as:
• Replacement of one entire blood volume within 24 hours, or
• Replacement of 50% of total blood volume (TBV) within 3 hours , or
• Transfusion of > 4 units of PRBCs in 1 h when on-going need is
foreseeable, or
• Transfusion of >10 units of packed red blood cells (PRBCs) in 24 h.
 Data regarding MBT in the paediatric population is scarce.
Definitions of MBT suggested for use in children are : transfusion of >50% TBV in 4 h, transfusion
>100% TBV in 24 h or transfusion support to replace on-going blood loss of >10% TBV/min.
(Blood Volume 70ml/kg in adult, 80ml/kg for about 1 month old).

4. Common Clinical conditions requiring
massive transfusion
 Massive transfusion occurs in settings, such as-
o Severe trauma,
o Ruptured aortic aneurysm,
o Surgery and
o Obstetrics complications.

5. Changing concepts in the management of
hemorrhagic shock.
 With better understanding of the pathophysiology of haemorrhagic
shock, resuscitation of patients with massive haemorrhage has
advanced from reactive to supportive treatment with fluid
Crystalloid, PRBC, and laboratory report based use of coagulation
factors, & use of proactive standardized protocols called MTPs.

6. Present Concept in the Resuscitation in
hemorrhagic shock
 A. The present concept is Permissive hypotension and minimal
volume resuscitation,(where systolic blood pressure is kept between 80–
100 mmHg, well tolerated while bleeding is controlled and have shown survival
benefit in several studies).
o It is widely practiced for ruptured abdominal aortic aneurysm;
but contraindicated in patients with traumatic brain and spinal injuries.
 B . Aggressive fluid resuscitation with crystalloids
(Previously recommended to achieve and maintain normal blood pressure associated with :
pulmonary oedema and acute lung injury; exacerbation of anaemia, thrombocytopenia &
coagulopathy due to haemodilution; and exacerbation of bleeding due to possible clot
disruption).
o .

7. Ideal Crystalloids for volume resuscitation
• L-isomer of LR causes less inflammation, immune dysfunction , and
mortality in critically ill patients and is recommended fluid of choice
in hemorrhagic shock patients.
• In children, isotonic and balanced crystalloid (20 mL/kg) is
recommended for initial resuscitation. Clear fluid volume should be
< 40 mL/kg to prevent dilutional coagulopathy and edema .
• NS or RL ; NS (pH 5.0) NS produces Hyperchlorimic Acidosis , RL ( pH
6.5), Alkalosis due to conversion of Lactate to Bicarbonate.

8. Whole Blood
 Earlier practice was to transfuse whole blood, but the
modern practice is to transfuse only components of the
blood; such as red blood cells, white blood cells, plasma,
clotting factors, and platelets as needed.
 Major limitation to the use of WB are;
 Requirement for type-specific blood,
 Patient blood Group is unknown frequently .(particularly during the
early phase of resuscitation).

9. Low titer group O whole blood (LTOWB)
 It is O group blood with low antibody titer.
 Low antibody titer is defined as whole blood with IgM anti-A and anti-B titer < 250.
• LTOWB is unseparated blood, collected from a donor with “low” IgM and/or IgG anti-A
and anti-B and can either be stored or given fresh (within 8-24 hours).
• The presence or absence of the Rhesus (Rh) (D) antigen is much less relevant during
hemorrhagic shock resuscitation; therefore, LTOWB is not defined by its Rh factor
status.
• Rh negative patients do not develop sensitivity to Rh positive blood until weeks after
exposure. Therefore, in the acute trauma setting, Rh positive blood can be
administered to Rh negative patients without significant risk of transfusion reaction
• The cold-stored LTOWB product is an FDA licensed product, with an IgM anti-A and
anti-B titer of < 150.

10. Whole Blood or Component therapy
Whole blood is better than
component therapy.
But availability in large quantity is a
problem in emergencies.
Adding preservative to whole blood
dilutes it by about 12%.
And there are concerns that cooling
it may have effects on platelet
function.
(Recent data suggests that platelet function in
cooled whole blood is preserved, but platelet
longevity is decreased.)
It contains a full complement of white
blood cells, and this may be related to
reports of venous thrombosis,
respiratory distress, and even graft vs
host disease.
Unfortunately, removing the white cells
(leukoreduction) also tends to remove
the platelets, and there is little
literature detailing the safety of this
practice.

11. Red cell transfusion
 The decision to administer red cell transfusion during resuscitation should include: assessment
of the patient's intravascular volume status, cardiopulmonary parameters, and the extent of,
or potential for, ongoing haemorrhage.
o Red cell transfusion is likely to be required when 30–40% blood volume is lost (approximately
2000 mL in an adult);
o Pre-transfusion compatibility testing should be done early.
o It is best practice to transfuse red cells of the same ABO and Rh group as the patient; however
if there are insufficient supplies of the patient's ABO group available locally, red cells of another
ABO compatible group may be released by the transfusion provider
o In an emergency situation uncrossmatched Group O, Rh negative red cells (especially for
females of childbearing age) may be appropriate.

12. PRBC
 Each unit of packed red blood cells (RBCs) contains approximately
200 mL of red cells and, in an adult, will raise the hematocrit by
roughly 3 percentage points unless there is continued bleeding.
 Correction of the deficit in blood volume with crystalloid volume expanders will
generally maintain hemodynamic stability, while transfusion of red cells is used
to improve and maintain tissue oxygenation .

13. Uncrossmatched Blood
 Due to the emergent need for blood products, routine pre-
transfusion testing is bypassed and uncrossmatched,(Group O RhD
negative) RBCs are often given.
 (This removal of safety assurances received from the antibody screen and product cross-
matching leaves alloimmunized patients at increased risk for acute or delayed hemolysis).
 In addition, residual plasma within Group O RBC units can accumulate when large
quantities of Group O RBC units are transfused.
 Thus, for A, B, or AB patients, it is safest to repeat the blood type, with particular consideration
of the reverse type, before resuming transfusion of RBCs of the patient’s own blood group.

14. Plasma
 Circulating coagulation factors have variable half-lives and are homeostatically
maintained.
o During massive hemorrhage, the acute nature of significant blood volume loss could lead to
uncompensated coagulopathy.
 Therefore, early transfusion of plasma-containing physiologic coagulation
factors intuitively should reverse this condition.
o  Until recently, universal Group AB plasma has been the standard product used during MT
when the patient’s blood group is initially unknown.
(Since Group AB donors comprise only approximately 4% of all eligible blood donors, and the availability of
Group AB plasma donors has been further reduced by the transfusion-related acute lung injury (TRALI)
mitigation strategies, Group AB plasma and platelet products remain scarce resources).
o  Use of Group A plasma with low titer anti-B agglutinin has been considered as a practical
alternative to Group AB plasma.( Group A US donors are approximately ten times more
abundant than AB donors).
 FFP takes 30-45 minutes for thawing and after thawing can be stored at 1-6°C for 24 hours.

15. FFP
 There is insufficient evidence to support or refute a specific
RBC:FFP:PLT ratio.
 transfusion should be based on clinical criteria & frequent
monitoring of laboratory values.
 Institutions should develop their own MTP (Massive Transfusion
Protocol) with locally agreed ratios of blood component therapy.
o Give FFP to maintain PT & APTT ≤ 1.5x mean control
o Usual dose is 15 ml/kg
o If the patient's blood group is unknown, give group AB FFP.
o Allow 1/2 hour thawing time.

16. Platelets
• Thrombocytopenia <50 x 109 /L can be anticipated after two blood
volume replacement due to dilution and increased consumption.
• Aim is to keep the platelet count >50 x 109 /L (or >100 x 109/L in
situations such as CNS injury or diffuse microvascular bleeding)
• The usual dose in an adult is 1 unit SDP/ 6units of RDP.
• The Protocol says transfuse blood products ( PRBC:FFP:RDP) 1:1:1
when you are following massive transfusion..

17. Storage of Platelets
• After collection from blood donors, platelets are typically stored between 20°C
and 24°C with constant agitation for up to 5 days.
• (While refrigeration (1°C–6°C) is associated with ↓decreased platelet viability and post-infusion
increments, cold platelets have been shown to more readily aggregate in vitro and to
have a better metabolic profile).
• During emergency resuscitation, the clinical emphasis often weighs more in
favor of achieving rapid hemostasis rather than a durable increase in platelet
count.
 Therefore, it has been suggested that refrigerated platelets dedicated for emergency
transfusion may have clinical benefits.

18. Dilutional coagulopathy in haemorrhagic
shock
o .During haemorrhagic shock, there is fluid shift from the interstitial to
the intravascular compartment that leads to dilution of the
coagulation factors.
o.This is further accentuated when the lost blood is replaced with
coagulation factor deficient fluids.
.Low colloid oncotic pressure giving rise to interstitial edema.

19. Cryoprecipitate
• FFP may supply enough fibrinogen to correct any deficiency but if
fibrinogen < 1 g/L  cryoprecipitate may be indicated
• Usual dose is 3–4 g of fibrinogen . (Worldwide, cryoprecipitate remains the
most common blood product used to replace fibrinogen and contains approximately 200–250
mg of fibrinogen per unit, your local transfusion provider can advise on the number of units to
provide ).
• In obstetrics haemorrhage, early DIC is often present so consider
cryoprecipitate early in this situation.
• Allow 1/2 hour thawing time
• Cryoprecipitate products are usually pooled units of five.
• It is plasma-derived blood component enriched in fibrinogen, factor VIII, factor XIII and von
Willebrand factor; generated by thawing fresh frozen plasma (FFP) at 1-6 degrees C (33.8-42.8
degrees F) and collecting precipitates by centrifugation.

20. Fibrinogen concentrate
 Fibrinogen is a coagulation factor with a large molecular weight and a long half-life.
 Worldwide, cryoprecipitate remains the most common blood product used to replace
fibrinogen and contains approximately 200–250 mg of fibrinogen per unit.
 A retrospective study correlating the fibrinogen level with mortality in critically injured patients
revealed that fibrinogen levels less than 180 mg dL−1 were significantly associated with higher
in-hospital death.
 In addition to the time delay from thawing the cryoprecipitate, the thawed product expires
within 6 hours in most countries.
 European guidelines recommend the initiation of fibrinogen replacement by fibrinogen
concentrate when the plasma fibrinogen level falls below 1.5 g L.
• fibrinogen concentrate is used in most European countries to treat acquired disorders of
fibrinogen
 Worldwide to treat congenital fibrinogen deficiency or dysfibrinogenemia.
 Fibrinogen concentrate: Concentrated fibrinogen derived from pooled human plasma and
available as pasteurized and lyophilized powder.

21. FIBRINOGEN CONTENT IN VARIOUS BLOOD PRODUCTS
Products Fibrinogen Content
1-10 unit of Cryoprecipitate 2500 mg / 150 ml
1 Unit of FFP 400 mg / 250 ml
1 Unit of PRBC < 100 mg
1 six pack of platelets 480 mg
1 unit of apheresis platelets 300 mg
1 unit of whole blood 1000 mg

22. Hemostatic therapies
 The use of lyophilized factor concentrates and pharmacologic agents during MT
has gained popularity as they can be stored and administered at the bedside to
avoid time delays due to product processing and issuing.
 In addition, this allows the use of target-specific treatment rather than the broad and non-
specific use of plasma to attempt to correct all coagulopathies.
 Three factor concentrates have been used in MT: prothrombin
complex concentrates (PCCs), recombinant-activated factor VII,
and fibrinogen concentrate.

23. Tranexamic acid
 Antifibrinolytics: {( such as aminocaproic acid or tranexamic acid (TXA)}, inhibit the
formation of plasmin. ( plasmin breaks down the fibrin-based clot).
 Therefore, they are used to improve the durability and firmness of the clot in order to enhance
clinical hemostasis.
 Dose: 1gm 6 hourly in PPH proved effective.
 In Trauma: Loading dose of 1gm over 10 minutes repeated 8 hourly.
 The largest prospective RCT utilizing antifibrinolytics is the Clinical Randomization of an
Antifibrinolytic in Significant Hemorrhage (CRASH-2) trial, a multicenter study that evaluated
more than 10,000 trauma patients.
 The data analyses revealed that timely administration of TXA (within 3 hours of injury) was
associated with a modest but highly significant reduction in both overall and bleeding-related
mortalities, but not in MOF or head injury.

24. Recombinant-activated factor VII (rFVIIa) and PCCs.
• With rapid activation of thrombin in the presence of adequate fibrinogen and platelets, the
early use of rFVIIa was associated with less blood product usage and lower mortality in military
patients requiring MT.
• The use of 3- or 4-factor PCCs( Prothrombin complex concentrates) in a MT setting is observed
due to its rapid availability and potent/rapid restoration of key vitamin K-dependent clotting
factors in a concentrated, low volume dose.
• PCCs may carry potential enhanced risk of  thrombosis in subsets of MT patients due to
patients’ increased circulating tissue factor and decreased plasma or endothelial anticoagulant
activity
 With the lack of safety evidence, European guidelines do not endorse the use of PCC in a MT
setting.
• Routine use of rFVIIa is not recommended due to lack of effect on mortality.
• It is not licensed for the prevention or management of haemorrhage in critically bleeding
patients.
• The MTP should include considerations for rFVIIa use.

25. Patients on Warfarin
 For life-threatening clinically significant bleeds: the consensus is to
use the maximum dose of Prothrombinex-VF.
 Prothrombinex (PTX-VF): 50 IU/kg
 When Prothrombinex(PTX –VF) is unavailable Vitamin K1 and FFP.
 Vitamin K1: 5–10 mg IV
 Fresh Frozen Plasma: 150–300 mL or 15 mL/kg.

26. Goals of Massive Transfusion Protocol
• Early recognition of blood loss.
• Maintenance of tissue perfusion and oxygenation by restoration
of blood volume and haemoglobin (Hb).
• Arrest of bleeding in combination with use of early surgical or
radiological intervention, and
• Judicious use of blood component therapy to correct
coagulopathy.

27. Targets of resuscitation in massive blood loss
• A. Mean arterial pressure (MAP) around 60 mmHg, systolic arterial
pressure 80-100 mmHg (in hypertensive patients one may need to target
higher MAP)
• B. Hb 7-9 g/dl (This should not be used alone as transfusion trigger; and, should
be interpreted in context with haemodynamic status, organ & tissue perfusion).
• C. INR <1.5; activated PTT < 42 s ( > 1.5 of normal value )
• D. Fibrinogen >1g/L
• E. Platelets >50 × 109/L, (>100 x 10^9 if head injury/ intracranial haemorrhage)
• F. pH > 7.2, Base Excess < -6, Lactate < 4
• G. Core temperature > 35.0°C
• Ionized Calcium > 1.1 mmol/L

28. Massive Transfusion Protocol
• 1.Massive transfusion protocols are activated ( by a clinician in response to massive bleeding ).
• 2. Generally this is activated after transfusion of 4-10 units.
• 3. MTPs have a predefined ratio of RBCs, FFP/cryoprecipitate and platelets units (random donor
platelets) in each pack (e.g. 1:1:1 or 2:1:1 ratio) for transfusion.
• 4. Once the patient is in the protocol, the blood bank ensures rapid and timely delivery of all
blood components together to facilitate resuscitation.
 MTPs are designed to interrupt the lethal triad of :
• Acidosis,
• Hypothermia and
• Coagulopathy
that develops with massive transfusion thereby improving outcome.
 By developing locally agreed and specific guidelines that include clinical, laboratory, blood bank
and logistic responses, clinicians can ensure effective management of massive blood loss and improve
outcome.

29. Lab values to be monitored include:
• PT/INR
• PTT
• Fibrinogen
• Platelet count
• Hct/Hgb
• ABG
• Electrolytes

30. Common Transfusion Pitfalls
• For females (of childbearing age whose blood type is not known)  O negative red
cells should be reserved.
• Male traumas of unknown ABORh  may receive O positive RBC.
• All patients should be switched to type-specific blood as soon as
their native type is discovered in blood bank.
• O negative RBC can be readily transfused if available, the non RBC
products like; FFP, PPH(SDP) & Cryoprecipitate may take time to
prepare.

31. Complications of Massive Transfusions
• Acidosis
• Hyperkalemia
• Hypothermia
• Citrate Toxicity
• Hypocalcaemia
• Hypomagnesaemia
• Usual Transfusion reaction problems.
• Late Complications.

32. Lethal Triad of
Massive Haemorrhage
Acidosis
Hypothermia
Coagulopathy.

33. Pathogenesis of
Coagulopathy in
Trauma

34. Acidosis:
 After 2 weeks of storage; PRBCs have a pH below 7.0, and each unit has an
acid load of approximately 6 mEq.
• One of these mEq of acid comes from the fact that PRBCs are made from venous
blood with a starting pH of 7.35, a second mEq is acquired in buffering the citric
acid in the anticoagulant, and 4 mEqs. are generated by glycolysis during PRBC
storage.
A pH decrease from 7.4 to 7.0 reduces the activity of FVIIa and FVIIa/TF by
over 90% and 60% respectively.
 Acidosis directly reduces activity of both extrinsic and intrinsic
coagulation pathways.

35. Genesis of hypothermia.
Factors contributing to hypothermia include:
• infusion of cold fluids and blood and blood products,
• opening of coelomic cavities and
• decreased heat production.
Coagulopathy due to hypothermia is not reflected in laboratory tests
as the samples are warmed during processing.

36. Hypothermia and its adverse effects.
o Hypothermia is a frequent pathophysiologic consequence of severe injury and subsequent
resuscitation .
o It is estimated that as many as 66% of trauma patients arrive in the emergency department
with hypothermia.
o Body temperatures less than 33°C produce a coagulopathy that is functionally equivalent to
factor deficiency states seen when coagulation factor concentrations are less than 50%.
o Thrombin generation on platelets is reduced by 25% at 33°C.
o The average size of aggregates formed by thrombin-activated platelets was decreased by
40% at 33°C and
o Platelet adhesion was reduced by 33% .
o Adverse clinical effects such as cardiac dysrhythmias, reduction in cardiac output, increase in
systemic vascular resistance, and a left shift in the oxy-hemoglobin saturation curve have
been described.

37. Hyperkalaemia:
 Potassium concentrations in PRBCs can range from 7 to 77 mEq /L
depending on age of stored blood. At transfusion rates exceeding 100-150
ml/min, transient hyperkalaemia is frequently seen.
 Development of hyperkalaemia will depend on the underlying renal function,
severity of tissue injury, and rate of transfusion.
 Also, acidosis secondary to hypoperfusion may worsen hyperkalaemia.
 Cardiac effects of hyperkalaemia are accentuated by hypocalcaemia.

38. Citrate toxicity
o1. 80 ml of citrate phosphate dextrose adenine solution present in each
blood bag contains approximately 3 g citrate.
o2. Unmetabolised citrate can then lead to hypocalcaemia,
hypomagnesemia and worsen the acidosis.
o3. Hypocalcaemia can lead to myocardial depression that manifests
earlier than hypocalcaemic coagulopathy.
o4. Calcium supplementation is thus required in most cases of MBT.
 A healthy adult can metabolize this load in 5 min.
 However, hypoperfusion or hypothermia associated with massive blood
loss can decrease this rate of metabolism leading to citrate toxicity.
 Hypotension not responding to fluids should alert the physician to this
complication.

39. Hypomagnesemia:
• Citrate also binds to magnesium and can lead to hypomagnesaemia
which can further accentuate effects of hypocalcaemia.
• Infusion of large amounts of magnesium poor fluid can also
contribute to hypomagnesemia.

40. Late complications of massive transfusion
1. Transfusion related acute lung injury (TRALI):
o The risk of TRALI increases with the number of allogenic blood and blood products transfused.
oThe exact pathologic mechanisms of TRALI have not been clearly understood and both
immunologic and nonimmunologic mechanisms have been suggested
2.SIRS.
3.Sepsis.
4.Thrombotic complications.

41. Guidelines
 Guidelines are designed to provide evidence-based, well-balanced
information regarding the benefits and limitations of therapeutic
interventions.
 Two major guidelines are available for MT:
a). European guidelines by the Task Force for Advanced Bleeding
Care in Trauma (updated in 2013) and the
b). Trauma Quality Improvement Program (TQIP)
recommendations from the American College of Surgeons.

42. European guidelines by the Task Force for Advanced
Bleeding Care in Trauma (updated in 2013)
• The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma was founded in 2004 and
included representatives of six relevant European professional societies.
• Recommendations were formulated to reflect current clinical concerns and areas in which new research data have
been generated.
• This guideline represents the fourth edition of a document first published in 2007 and updated in 2010 and 2013.
 The guideline now recommends that patients be transferred directly to an appropriate trauma
treatment centre and encourages use of a restricted volume replacement strategy during initial
resuscitation.
 Best-practice use of blood products during further resuscitation continues to evolve and should
be guided by a goal-directed strategy.
 The identification and management of patients pre-treated with anticoagulant agents
continues to pose a real challenge, despite accumulating experience and awareness.

43. National Blood Authority, Australia Guidelines on MTP

45. Preparation for Massive transfusion
.Essentials of massive Transfusion:
o 1. Wide bore cannula.
o 2. Warming devices: In-line fluid warmers and surface warmers.
o 3. Continuous core temperature monitoring.
o 4. Invasive arterial pressure monitoring.
o 5. Adequate amount of colloid (gelatins), crystalloid, infusion sets
and IV calcium preparations.
o 6. Communication with blood bank about emerging massive blood
loss situation.
o 7. Adequate manpower for sending samples for investigations and
getting blood and blood products.
o 8. Point-of-care testing is highly desirable: Arterial blood gas (ABG)
and thromboelastograph (TEG).
ABG with haemoglobin (Hb), electrolyte and lactate levels, repeated hourly, are useful in
directing therapy.

46. Inadequate resuscitation:
 Hypo perfusion leads to  lactic acidosis, systemic inflammatory
response syndrome (SIRS), disseminated intravascular coagulation
and multi organ dysfunction.
 It also increases the expression of thrombomodulin on
endothelium, which then complexes with  thrombin, which in turn
leads to  a reduced amount of thrombin available to produce
fibrin and increases the circulating concentrations of anticoagulant
activated protein C, which worsens the coagulopathy.

47. Clinical Monitoring
 A. Essential to monitor: Electrocardiogram, capnometry, pulse
oximetry, arterial blood pressure, core temperature, and urine
output.
 B. Invasive arterial pressure measurement .allows beat-to-beat pressure
measurement and has greater accurate, the arterial catheter allows frequent
arterial blood sampling, modern haemodynamic monitors calculate pulse
pressure variation which is a more specific indicator of volume responsiveness.
 C. Central venous catheters are useful for assessment of the
haemodynamic status( preload), administration of vasoactive agents and blood
sampling.

48. Lab Monitoring
 Laboratory monitoring: Laboratory values should be obtained
frequently. The time lag between collection of samples and obtaining the
reports is a serious limitation in their utility during rapid on-going blood loss.
 Recommended lab tests include: Hb%, platelet count, prothrombin
time, partial thromboplastin time (PTT), fibrinogen, potassium,
ionized calcium, ABG, Lactate, SVO2.
(ABG for acid base status and central venous oxygen saturation/lactate as an indicator of tissue
hypoperfusion).

49. Thromboelastography (TEG)
 Thromboelastography (TEG) is test of the visco elastic properties of
blood that examines the entire haemostatic system including
platelet function and fibrinolytic system and is particularly useful in
complicated coagulopathies.
• Its rapid availability of results helps in timely intervention.

50. Management of loss of blood components
• Mild to moderate blood loss can be managed with crystalloid or
colloid infusions alone.
• Coagulopathy during cardio pulmonary bypass (CPB): Heparin given
before CPB and hypothermia lead to platelet dysfunction that has
been shown to be a major cause for bleeding in patients on CPB.
• Postpartum haemorrhage: Recent studies suggest that acquired
fibrinogen deficiency may be the major coagulation abnormality
associated with obstetric bleeding[ which may be compounded by
dilutional coagulopathy and hyperfibrinolysis.

51. Summery
Understanding the complex pathophysiology of massive blood loss
and its replacement is crucial to a successful outcome.
Recent evidence supports early use of coagulation factors to improve
outcome.
 Indian hospitals should formulate MTPs suited to their need and
resources to improve survival in massive blood loss.

52. Conclusion
• While these recommendations provide guidance for the diagnosis
and treatment of major bleeding and coagulopathy, emerging
evidence supports the author group’s belief that the greatest
outcome improvement can be achieved through education and the
establishment of and adherence to local clinical management
algorithms.

53. References
• National Blood Authority. Patient Blood Management Guidelines:
Module 1 – Critical Bleeding/Massive Transfusion. [cited 2011 Jun
30]. Available from: http://www.nba.gov.au.
• American College of Surgeons (ACS) Committee on Trauma.
Advanced trauma life support for doctors: ATLS student course
manual ACS, Chicago 2008.
• Tran HA, Chunilal SD, Harper PL, Tran H, Wood EM, Gallus AS. An
update of consensus guidelines for warfarin reversal. MJA
2013;198(4);198–199
•