Massive Transfusion Protocol (AAST/ACS 2024)

Algorithm Steps

1. ▶

   Start

   Hemorrhagic Shock

   Patient with significant hemorrhage or anticipated massive transfusion

   1. ◆

      Decision

      MTP Activation Criteria

      Assess need for massive transfusion

      • ABC Score ≥2 or Clinical judgment
      • Penetrating trauma + SBP ≤90 + HR ≥120
      • Anticipated need for >10 units PRBCs in 24h
      • Unstable despite 2L crystalloid
      • Active hemorrhage with shock
      1. ⚠

         Warning

         ACTIVATE MTP

         Call blood bank, mobilize team

         • Call blood bank with patient identifier
         • Request MTP cooler (typically 6:6:1 or 4:4:1)
         • Notify surgical/trauma team
         • Prepare for OR if surgical source
         1. ●

            Action

            Initial Resuscitation

            Balanced blood product administration

            • 1:1:1 ratio (or close): RBC:Plasma:Platelets
            • Whole blood if available (preferred)
            • Use rapid infuser/blood warmer
            • Permissive hypotension (SBP 80-90) until surgical control
            • Avoid crystalloid boluses
            1. ●

               Action

               Tranexamic Acid

               Give within 3 hours of injury

               • 1g IV bolus over 10 min
               • Then 1g IV over 8 hours
               • Most benefit if given <1 hour
               1. ◆

                  Decision

                  TEG/ROTEM Available?

                  Viscoelastic testing for goal-directed therapy

                  1. ●

                     Action

                     TEG/ROTEM-Guided Therapy

                     Target specific deficiencies

                     • Prolonged R/CT: Give plasma
                     • Low MA/MCF: Give platelets
                     • Low fibrinogen/α-angle: Give cryoprecipitate
                     • Fibrinolysis: Consider additional TXA
                     1. ◆

                        Decision

                        Hemorrhage Controlled?

                        Surgical or interventional control achieved

                        1. ●

                           Action

                           Continue MTP

                           Ongoing hemorrhage

                           • Continue product administration
                           • Urgent surgical control
                           • Consider interventional radiology
                           • REBOA if indicated
                        2. ●

                           Action

                           Deactivate MTP

                           Hemorrhage controlled

                           • Notify blood bank to stop coolers
                           • Return unused products
                           • Continue monitoring/correcting coagulopathy
                           • Prevent/treat hypothermia and acidosis
                           1. ✓

                              Outcome

                              Patient Stabilized

                              Hemorrhage controlled, coagulopathy corrected

                  2. ●

                     Action

                     Continue 1:1:1 Empirically

                     Without TEG, maintain balanced resuscitation

                     • Continue 1:1:1 ratio
                     • Check labs q30-60min: CBC, PT/PTT, fibrinogen
                     • Target: Plt >50, INR <1.5, Fib >1.5 g/L
            2. ●

               Action

               Calcium Replacement

               Counter citrate toxicity

               • Calcium chloride 1g IV per 4 units blood
               • Or calcium gluconate 2-3g
               • Target iCa >1.0 mmol/L
               • Monitor with each cooler