The document discusses a massive transfusion protocol (MTP) for managing massive blood loss. It defines massive transfusion as replacing over half the total blood volume within 3 hours or transfusing more than 10 units in 24 hours. Massive bleeding can cause acidosis, hypothermia, and coagulopathy, known as the "lethal triad." MTPs are designed to interrupt this triad and improve outcomes. The protocol outlines assessing triggers, activating a response team, and proceeding through rounds of rapidly transfusing blood products like packed red blood cells, fresh frozen plasma, platelets and calcium while monitoring lab values to guide hemostatic resuscitation.

1. Massive transfusion protocol
Presenter - Dr Ram Kishore Singh

2. Classification of hemorrhagic shock

3. Definitions - Massive blood transfusion
• Replacement of one entire blood volume within 24 h
• Transfusion of >10 units of whole blood in 24 h
• Transfusion of >5 units of whole blood within 4 h
• Transfusion of >4 units of PRBCs in 1 h when on-going need is
foreseeable
• Replacement of 50% of total blood volume (TBV) within 3 h

4. Metabolic abnormality
• In bleeding patients, there would be hypoxia and acidosis due to
blood loss
• Blood loss also leads to-
-loss of clotting factors and,
-hypothermia due to heat loss
• Acidosis impair the ability of blood to clot which may worsen
coagulopathy
Triad - Acidosis, hypothermia and, coagulopathy

5. PRINCIPLES OF MANAGEMENT OF MASSIVE BLOOD LOSS
• Management of intra vascular volume loss.
• Management of loss of blood components.
• Correction of metabolic abnormalities.
MTPs are designed to interrupt the lethal triad of acidosis,
hypothermia and coagulopathy that develops with massive
transfusion thereby improving outcome.

6. Assessment of blood component (ABC) score
Components Points
Penetrating injury 1
FAST positive 1
Heart rate > 100/min 1
Systolic BP <90 mmHg 1
Trigger for MPT - ABC score ≥2
(Accuracy of prediction of MTP 75%)

7. Adult massive transfusion protocol
Triggers-
• ABC score ≥2
• Trauma to major blood vessel during surgery
• Upper GI bleeding (Variceal/Non variceal)
• Postpartum hemorrhage(PPH)
• Penetrating traumatic injury

8. Massive transfusion protocol
• Call blood bank & inform MTP to be initiated
• Divide teams into ABC, assign each team to do specific task
• Team A - Administer blood components
• Team B - Record keeping, sampling, labeling, writing notes
• Team C - Go to blood bank and get blood components to hospital

9. Pressurized rapid transfusion
• Ensures blood component reach into
patient’s body on time
• Ensures infusion matched blood loss
thereby increases chances of survival
• Has in-line warmer that decreases chances
of hypothermia and thereby coagulation
problems are taken care of and hemostasis
achieved

10. Round 1
• Give Inj tranexamic acid 1gm IV stat and then 8 hourly
• Send CBC, coagulation profile, fibrinogen level and ABG
• Connect pressurized rapid transfuser
• Transfuse -
-4 units PRBC (saline cross matched - O -ve) and
-2 units FFP (AB+ve)
Reassess the patient, if no improvement then start round 2

11. Round 2
• Transfuse-
-4 units PRBC
-4 units FFP
-1 unit SDP or 6 units PRP
• Collect lab report to evaluate coagulopathy and acidosis
• Give Inj 10% Calcium gluconate 10ml slow IV to prevent tetany
• Cryoprecipitate infusion if fibrinogen level <100 mg/L
Reassess the patient, if no improvement then start round 3

12. Round 3
• Repeat round 2 + Factor VIIa
Indications to give Factor VIIa -
• Surgical hemostasis
• Temperature(37℃) and PH has been stabilized but patient
is still bleeding

13. Complications of massive transfusion protocol
• Coagulopathy
• TRALI (Non cardiogenic pulmonary edema)
• TACO (Cardiogenic pulmonary edema)
• Hyperkalemia
• Hypocalecemia
Note
Identify the reason for respiratory distress after massive transfusion protocol

14. Thank You