Hemorrhagic Shock
Patient with significant hemorrhage or anticipated massive transfusion
All Pathways
Hematology & OncologyEmergency
Massive Transfusion Protocol (AAST/ACS 2024)
Massive Transfusion Protocol (AAST/ACS 2024): Hemorrhagic Shock → MTP Activation Criteria → ACTIVATE MTP → Initial Resuscitation → Tranexamic Acid.
Pathway Overview
13 steps
Algorithm Steps
13 total
01Start 02Decision 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
03Warning 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
04Action 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
05Action 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
06Decision TEG/ROTEM Available?
Viscoelastic testing for goal-directed therapy
07Action 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
08Decision Hemorrhage Controlled?
Surgical or interventional control achieved
09Action Continue MTP
Ongoing hemorrhage
- Continue product administration
- Urgent surgical control
- Consider interventional radiology
- REBOA if indicated
- Path rejoins step 08Shared downstream outcome
10Action Deactivate MTP
Hemorrhage controlled
- Notify blood bank to stop coolers
- Return unused products
- Continue monitoring/correcting coagulopathy
- Prevent/treat hypothermia and acidosis
11Outcome Patient Stabilized
Hemorrhage controlled, coagulopathy corrected
12Action 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
- Path rejoins step 08Shared downstream outcome
13Action 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
- Path rejoins step 06Shared downstream outcome
Guideline Source
AAST/ACS Clinical Protocol for Damage-Control Resuscitation
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Trigger criteria vary by institution
- Blood product availability may limit implementation
- Does not replace surgical hemorrhage control
- TEG/ROTEM interpretation requires training
Applicable Regions
USEUGlobal
EU: Component therapy ratios may vary by center
US: Whole blood increasingly available at trauma centers
Version 1Next review: 2027-01-01
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Frequently Asked Questions
What is the Massive Transfusion Protocol (AAST/ACS 2024)?
The Massive Transfusion Protocol (AAST/ACS 2024) is a emergency clinical algorithm for Hematology & Oncology. It provides a structured decision tree to guide clinical decision-making, based on AAST/ACS Clinical Protocol for Damage-Control Resuscitation.
What guideline is the Massive Transfusion Protocol (AAST/ACS 2024) based on?
This algorithm is based on AAST/ACS Clinical Protocol for Damage-Control Resuscitation (DOI: 10.1097/TA.0000000000004088).
What are the limitations of the Massive Transfusion Protocol (AAST/ACS 2024)?
Known limitations include: Trigger criteria vary by institution; Blood product availability may limit implementation; Does not replace surgical hemorrhage control; TEG/ROTEM interpretation requires training. Individual patient factors may require deviation from these recommendations.
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