Adult trauma with critical bleeding
Adult trauma patient with life-threatening bleeding, or likely to need massive transfusion.
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Hematology & OncologyEmergency
Massive Transfusion Protocol (Adult Trauma)
Massive Transfusion Protocol (Adult Trauma): Adult trauma with critical bleeding → Not for children, birth-related or GI bleeding → Criteria for MHP act...
Pathway Overview
16 steps
Algorithm Steps
16 total
01Start 02Warning Not for children, birth-related or GI bleeding
This pathway is for adult trauma. Pregnant trauma patient: use it with the obstetric team.
- Children: use the weight-based paediatric MHP
- Obstetric (birth-related) haemorrhage: use the obstetric MHP. Pregnant trauma ≥20 weeks or uterus above the umbilicus: manual left uterine displacement; obstetric advice on BP target
- GI bleeding: do not give routine TXA; use the GI bleeding pathway
03Decision Criteria for MHP activation met?
Any one: ABC score ≥2, shock index ≥1, expected ≥5 units RBC in 4 h, or clinical judgement. Beta-blockers, a pacemaker or older age can hide shock.
- ABC score ≥2 (penetrating injury, SBP ≤90 mmHg, HR ≥120/min, positive FAST)
- Shock index (HR/SBP) ≥1 with active bleeding
- Expected need for ≥5 units RBC in 4 h
- Clinical judgement of critical bleeding
- If Yes
- Criteria met
04Warning Criteria met: activate MHP now
Call the blood bank and the trauma team now. Ask about known refusal of blood components. Pack contents follow the local MHP.
- Tell blood bank: MHP activation, patient ID and location
- Stop the bleeding early: direct pressure, tourniquet for limb bleeding, pelvic binder; then surgery, angioembolisation or endoscopy
- Group unknown: group O red cells, O RhD-negative for females ≤50 years or if sex or age is uncertain. Send group and crossmatch; change to group-specific as soon as possible
05Warning TBI, spinal cord injury or anticoagulant: read first
Suspected TBI or spinal cord injury: no permissive hypotension (contraindicated).
- TBI: keep SBP ≥110 mmHg (age 50–69: ≥100 mmHg). Severe TBI (GCS ≤8): also MAP ≥80 mmHg; platelets >100 ×10⁹/L
- Spinal cord injury: keep MAP at least 75–80 mmHg, not above 90–95 mmHg
- Anticoagulant or antiplatelet: start reversal now (see anticoagulant reversal pathway)
06Action Balanced blood component resuscitation
Give blood components early. No TBI or spinal cord injury: SBP 80–90 mmHg until major bleeding stops. Older age: use this lower target with caution. Chronic hypertension: it may be contraindicated.
- Aim for RBC:FFP:platelets 1:1:1 (4 RBC : 4 FFP : 1 adult platelet unit); never below 2:1:1
- No TBI or spinal cord injury: SBP 80–90 mmHg (MAP 50–60 mmHg) until major bleeding stops
- TBI: SBP ≥110 mmHg (age 50–69: ≥100 mmHg); severe TBI (GCS ≤8): MAP ≥80 mmHg. Spinal cord injury: MAP ≥75–80 mmHg
- Rapid infuser with blood warmer; actively warm to 36–37 °C (<35 °C is critical)
- Limit crystalloid; no large crystalloid boluses
- Target BP not reached despite blood components: add noradrenaline; do not use it in place of blood
- Whole blood only where the local blood service supplies it
07Action Tranexamic acid within 3 h of injury
Give as soon as possible. Do not wait for viscoelastic results.
- Adult: 1 g IV over 10 min, then 1 g IV over 8 h
- Do not start more than 3 h after injury
- Not for GI bleeding
08Action Calcium replacement
Citrate in blood components lowers ionised calcium (iCa). Keep iCa 1.1–1.3 mmol/L.
- Check iCa at activation, then after every 4 units RBC
- iCa <1.1 mmol/L (adult): 10% calcium chloride 10 mL IV (preferred) or 10% calcium gluconate 30 mL IV (similar calcium dose)
- Calcium chloride: give slowly into a large or central vein
- iCa <1.0 mmol/L is critical: treat now and recheck
09Decision Viscoelastic testing (TEG/ROTEM) available?
Use it with the MHP, not in place of it. Interpretation needs training.
- If Yes
10Action Yes: TEG/ROTEM-guided therapy
Keep the MHP running. Treat the deficit the test shows, with local device thresholds.
- Low functional fibrinogen (e.g. FIBTEM): cryoprecipitate or fibrinogen concentrate
- Low clot strength with normal fibrinogen: platelets
- Prolonged clotting time (CT or R time): FFP
- Hyperfibrinolysis: confirm TXA given; get haematology advice
- Also check labs after every 4 units RBC
11Decision Bleeding controlled?
Surgical, radiological or endoscopic control achieved, and no ongoing critical bleeding.
- If Yes
12Action Yes: stop the MHP
Tell the blood bank. Move to targeted correction guided by lab results.
- Return unused components to the blood bank promptly
- Correct coagulation, iCa, temperature (36–37 °C) and acid-base against lab results; Hb target 70–90 g/L
- Watch for rebleeding; reactivate the MHP if needed
13Outcome Bleeding controlled, MHP stopped
Continue targeted correction and monitoring in ICU or theatre.
If No14Action No: continue MHP and get source control
Critical bleeding continues.
- Continue blood components with lab-guided replacement
- Urgent surgery or angioembolisation
- REBOA: only in trained centres, for non-compressible haemorrhage
- rFVIIa: not routine; only when all other measures fail (off-label)
- Path rejoins step 11Shared downstream outcome
If No15Action No: continue ratio-based MHP with lab targets
Check labs at activation and after every 4 units RBC.
- Labs: FBC, PT/INR, APTT, fibrinogen, iCa, blood gas with lactate, temperature
- Fibrinogen <2.0 g/L (NBA critical level; European trigger ≤1.5 g/L): give 3–4 g (cryoprecipitate 10 units whole-blood or 4 units apheresis, or fibrinogen concentrate)
- Platelets <50 ×10⁹/L (TBI: <100 ×10⁹/L): give platelets
- PT or APTT >1.5 × normal (INR >1.5): give FFP
- Critical: temperature <35 °C, pH <7.2, base excess <−6 mmol/L, lactate >4 mmol/L
- Red cells: Hb target 70–90 g/L (Hb lags behind blood loss in active bleeding)
- Path rejoins step 11Shared downstream outcome
If No- Criteria not met
16Outcome Criteria not met: standard resuscitation
Treat the bleeding source. Bleeding or at risk of major bleeding, and less than 3 h from injury: tranexamic acid 1 g IV over 10 min, then 1 g IV over 8 h. Reassess often. Activate the MHP if criteria develop.
Guideline Source
The European guideline on management of major bleeding and coagulopathy following trauma, 6th edition (Rossaint et al., Crit Care 2023)
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Adult trauma only: children, obstetric and GI bleeding need their own protocol
- Follow your local major haemorrhage protocol (MHP) pack contents and blood bank process
- Does not replace surgical or radiological haemorrhage control
- TEG/ROTEM thresholds are device-specific and need trained interpretation
Contraindicated Populations
Children (use paediatric MHP)Obstetric haemorrhage (use obstetric MHP)Non-trauma bleeding, including GI bleeding (permissive hypotension and TXA steps do not apply)Suspected TBI or spinal cord injury: permissive hypotension contraindicated
Applicable Regions
AUNZUSEUGlobal
AU: Use the NBA 2023 critical bleeding guideline and the local MHP. Lifeblood does not list whole blood as a hospital component. 1 adult platelet unit = 4 donor units. Fibrinogen concentrate for critical bleeding is off-label.
EU: European trauma bleeding guideline 6th edition (2023); ratio or factor-concentrate strategy per centre.
NZ: Use the local MHP and NZ Blood Service product information for component doses.
US: Follow the AAST/ACS-COT 2024 damage-control resuscitation protocol (LaGrone 2024) and the local MTP. Low-titre group O whole blood is available at some trauma centres.
Version 2Next review: 2027-09-30
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Frequently Asked Questions
What is the Massive Transfusion Protocol (Adult Trauma)?
The Massive Transfusion Protocol (Adult Trauma) is a emergency clinical algorithm for Hematology & Oncology. It provides a structured decision tree to guide clinical decision-making, based on The European guideline on management of major bleeding and coagulopathy following trauma, 6th edition (Rossaint et al., Crit Care 2023).
What guideline is the Massive Transfusion Protocol (Adult Trauma) based on?
This algorithm is based on The European guideline on management of major bleeding and coagulopathy following trauma, 6th edition (Rossaint et al., Crit Care 2023) (DOI: 10.1186/s13054-023-04327-7).
What are the limitations of the Massive Transfusion Protocol (Adult Trauma)?
Known limitations include: Adult trauma only: children, obstetric and GI bleeding need their own protocol; Follow your local major haemorrhage protocol (MHP) pack contents and blood bank process; Does not replace surgical or radiological haemorrhage control; TEG/ROTEM thresholds are device-specific and need trained interpretation. Individual patient factors may require deviation from these recommendations.
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