Massive haemorrhage and major transfusion protocol — Rapid

Synopsis

Activate coordinated haemorrhage control early, deliver safe empirical component support, prevent lethal physiological deterioration and transition rapidly to targeted haemostasis.

First-line management is immediate major-haemorrhage activation plus anatomical bleeding control; transfusion is support, not source control.
Activate on physiology, bleeding rate, mechanism and poor response rather than waiting for an arbitrary unit count or one risk score.
Obtain correctly labelled pretransfusion samples before blood if this does not delay resuscitation and tell the laboratory about pregnancy potential, antibodies and special requirements.
Use approved emergency group O red cells until the laboratory authorises group-specific blood, then switch promptly to preserve O D-negative stock.
For adult major trauma with active bleeding, NICE recommends plasma and red cells in a 1:1 ratio initially, changing to laboratory-guided ratios as soon as possible.
Do not extrapolate a trauma 1:1 ratio automatically to every gastrointestinal, surgical or obstetric bleed; follow the context-specific local major-haemorrhage pack.
Give tranexamic acid as soon as possible for major trauma with active or suspected active bleeding and do not give it more than three hours after injury unless hyperfibrinolysis is demonstrated.
Prevent the lethal cycle of hypothermia, acidosis and coagulopathy with active warming, rapid source control and appropriate blood rather than excessive cold crystalloid.
Monitor ionised calcium frequently because citrate in blood products causes hypocalcaemia, impaired contraction and worsening coagulation; replace under the local protocol.
Target platelets, fibrinogen and plasma using frequent laboratory or validated viscoelastic results; general and obstetric fibrinogen targets differ.
Reverse anticoagulants rapidly with the specific or PCC-based pathway; warfarin-associated major bleeding needs four-factor PCC plus intravenous vitamin K, not FFP first-line.
Nominate a team leader and transfusion coordinator, count components and communicate both escalation and stand-down to the laboratory.

Key red flags

Persistent hypotension, tachycardia, altered consciousness, mottling, rising lactate or ongoing visible bleeding despite initial resuscitation indicates uncontrolled haemorrhagic shock.

A normal early haemoglobin does not exclude catastrophic acute blood loss because red cells and plasma are initially lost together.

Falling fibrinogen, prolonged clotting, thrombocytopenia, hypothermia, acidosis and low ionised calcium predict haemostatic failure and worsening mortality.

Pelvic, retroperitoneal, gastrointestinal, obstetric or postoperative bleeding can be concealed; unexplained shock requires immediate source imaging or intervention without repeated ward observation.

Failure to communicate cessation of bleeding to the transfusion laboratory wastes scarce components and increases incompatible handover and overload risk.

Investigation priorities

First-line: group and antibody screenFirst stepFirst line

Enable rapid transition from emergency group O to group-specific and antigen-appropriate blood.

First-line: FBC, PT, APTT and fibrinogenFirst line

Track anaemia, platelet loss, factor deficiency and fibrinogen depletion.

Management branches

ActivateMobilise the whole pathway

Bleeding and physiology suggest life-threatening or rapidly escalating blood loss.

Call the major-haemorrhage number and summon the appropriate procedural, anaesthetic, critical-care and transfusion teams.
State identifiers, location, cause, pregnancy potential, antibodies and urgency; assign a component coordinator and recorder.
Apply immediate source control, establish access, send correctly labelled samples and start active warming.

Key medicines

Tranexamic acid in major traumaGive 1 g intravenously over 10 minutes as soon as possible after injury, followed by 1 g intravenously over 8 hours; start within 3 hours of injury and do not use later unless laboratory evidence of hyperfibrinolysis supports it.Use the obstetric, surgical or gastrointestinal protocol rather than automatically copying the trauma regimen. Reduce repeated dosing in renal impairment under the product guidance, assess thrombosis and seizure risk and never administer by the intrathecal route; route confusion is frequently fatal.

Calcium chloride during major transfusionWhen ionised hypocalcaemia develops during rapid major transfusion, give 10 mL of 10% calcium chloride intravenously, providing about 6.8 mmol calcium, through secure central or large-bore access under the local protocol and repeat according to ionised calcium and ECG response.Calcium chloride is vesicant and extravasation can cause tissue necrosis; calcium gluconate is safer peripherally but provides less elemental calcium per volume. Use blood-gas monitoring rather than blind repeated dosing and avoid simultaneous administration through the same line as bicarbonate or phosphate-containing solutions.

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