The protocol can be initiated at any time during the patient’s hospitalization, including before arrival to the Massachusetts General Hospital (MGH).

Appropriate candidates include the following:

• Any patient with an initial blood loss of at least 40% of blood volume or in whom it is judged that at least 10 units of blood replacement is immediately required

• Any patient with a continuing hemorrhage of at least 250 mL/h

• Any patient, when clinical judgment is made such that blood loss as identified in “A” and “B” is imminent

Once the decision is made to initiate this protocol, the appropriate physician needs to do the following:

• Notify the blood bank with the age and gender of the patient.

• Ensure that a properly labeled blood bank sample is obtained and sent to the blood bank.

A transfusion medicine faculty member is on call at all times to assist in transfusion support.

RBC selection

• 4 units of emergency-release, uncrossmatched group O whole blood will be released for all emergency transfusion requests. After the initial 4 units of whole blood, group O pRBCs or ABO compatible pRBCs will be used.

Blood component requests After the initial assessment, if >10 total units are expected to be needed, the clinical team should request pRBCs and components according to the anticipated needs of the patient and guided by laboratory testing.

It is essential that the clinical team communicates to the blood bank when the patient is being moved to a different location.

Laboratory monitoring for ongoing blood support in cases requiring >10 units of RBCs:

• Transfusion support should be individualized for each patient.

• The following general guidelines apply:

  • Check Hgb, platelet count, INR, and fibrinogen after each blood volume lost/infused.

  • Include the number of “cell saver” units in the tally of pRBCs.

  • Target a ratio of 2 pRBCs to 1 FFP during the course of acute bleeding.

  • Anticipate fibrinolysis and treat with antifibrinolytics if there is ongoing diffuse bleeding.

  • Verify that the INR is <2.5 and fibrinogen >100. Values outside these ranges may indicate systemic fibrinogenolysis, DIC, or hemodilution.

  • In the absence of platelet transfusion, anticipate a halving of the platelet count with each blood volume resuscitation. Transfuse platelets to maintain an anticipated platelet count >50 000 µL.

  • A stat AST or ALT can be used to document shock liver (values >800 IU/mL), which is an independent indication for antifibrinolytic therapy; and if accompanied by ongoing shock, may indicate futility of resuscitation.

• Monitor and treat abnormalities of ionized Ca²⁺, K⁺, pH, and temperature.

Not all patients with massive injuries can be saved. The decision to withdraw support for these patients should be made by consensus of the treating team and the available resources.