Massive Hemorrhage Protocol

Introduction

MH Definitions

• Several definitions have been used to define MH and massive transfusion (MT).
• Based on volume lost, MH has been defined as:
  • Loss of greater than one blood volume (BV) in 24 hours,
  • 50% of BV lost in 3 hours, or
  • greater than 10% of BV lost every 10 minutes.
• Historically, MT was defined as the transfusion of ten or more units of whole blood or RBCs in 24 hours. Ultra-massive transfusion has been defined as using 20 or more units in 24 or 48 hours.
• Critical administration threshold for 1 hour (CAT-1) is an alternative functional definition involving administering three or more units of RBCs or whole blood over one hour.¹
• The Resuscitation Intensity (RI) score is similar to CAT but uses four or more blood components (all blood products and fluids) in 30 minutes as a starting point.¹
• In children, MT is defined as:
  • More than 40 mL/kg total components in 24 hours (combat trauma) or
  • More than 40 mL/kg total components or 20 mL/kg RBC over 4-6 hours (civilian trauma).²
    • Etiology: Trauma causes 50% of MTP activations; firearms are now the leading cause of child death in the United States. Medical and surgical bleeding evenly account for the other 50% of MTP activations.
    • Adult and pediatric MH mortality: About two-thirds of deaths due to traumatic hemorrhage occur in the first 6 hrs.
    • Pediatric MH 28-day mortality: Highest in medical patients (65%), then trauma (36%) and surgery (24%).3 In trauma, more than 50% of mortality occurs due to central nervous system injury.
    • The benefits of MTP implementation: Unlike adults, MTP has not improved 30-day mortality rates in children, which are 2-3 times higher (35.3-47.1%) due to their unique size, anatomy, physiology, and increased risk for adverse transfusion events.

MHP Activation and Patient Management

• Key protocol elements (see Table 1 below) should be adapted to local resources.
• Ensure clear communication of activation/deactivation, critical lab results, patient location changes, and use of patient hand-over tools.
• Emphasize early strategies to STOP bleeding.
• Plan a rapid transition from ratio-based to goal-directed transfusion; consider whole blood.
• There is no specific threshold at which cross-matched RBCs should be avoided based on the number (or volume) of uncross-matched O-negative RBC units administered. Transition as soon as possible to cross-matched PRBCs.
• Utilize blood conservation strategies (e.g., restrictive transfusion thresholds, tranexamic acid, and autologous red blood cell scavenging).
• Mitigate/treat complications from massive hemorrhage or transfusion, including metabolic derangements (e.g., ↑ K+, ↓ Ca²⁺), acidosis, coagulopathy, and hypothermia.
• Ensure regular practice audits and continuous quality improvement.

Table 1 (cont.)

^aShock index is the heart rate divided by systolic blood pressure. A normal shock index is 0.5-0.7. In trauma patients, a shock index greater than 0.9 is associated with an increased risk of transfusion and mortality.
^bThere are several validated scores to predict massive transfusion in adult trauma patients.⁴ The ABC score is based on four clinical criteria, each weighted at one point.

• Penetrating mechanism of injury
• Positive abdominal FAST (Focused Assessment with Sonography for Trauma)
• Systolic blood pressure ≤ 90 mmHg and
• Heart rate ≥ 120 beats/minute).

The TASH score is calculated using multiple clinical and laboratory variables, and each variable is assigned a certain number of points based on its association with severe hemorrhage.

• Systolic blood pressure
• Hemoglobin level
• Positive abdominal FAST
• Heart rate
• Gender
• Pelvic fracture and complex long bone fractures

^cDamage control resuscitation (DCR) aims to avoid the lethal triad of hypothermia, acidosis, and coagulopathy. The fundamental tenets of DCR include

• Control hemorrhage
• Avoid hypotension
• Ensure adequate oxygen delivery
• Limit crystalloids
• Administer warmed blood components and
• Quickly progress from ratio-based to laboratory-guided (goal-directed) hemostatic resuscitation.

^dMeasures to STOP bleeding include

• Surgery (vessel ligation, damage control laparotomy, packing, and direct pressure),
• Mechanical (tourniquets/pelvic binder, hemostatic gauze, balloon tamponade for gastrointestinal bleeding),
• Endovascular technique (radiologic embolization or stenting) and
• Topical hemostatic agents (e.g., gelatin sponge).

^eABC-D tool is similar to the adult ABC tool but replaces the heart rate and blood pressure thresholds with an age-appropriate shock index pediatric adjusted (SIPA) and incorporates measures of inadequate oxygen delivery (base deficit > – 8.8 and lactate >3.5 mmol/L)

Abbreviations: CBC=complete blood count (hemoglobin, white blood cell, and platelet count); CHD=congenital heart disease; CAT=critical administration threshold; RI=resuscitation intensity; MHP=Massive Hemorrhage Protocol; RBCs=red blood cells; TXA=tranexamic acid; TBI=traumatic brain injury; QI=quality indicator.

Treatment thresholds are similar between adults and children. Some exceptions are described below.

a. In the setting of massive hemorrhage, the anticipated rise in hemoglobin may be less than expected, requiring a 20 mL/kg dose of RBCs.
b. Higher hemoglobin treatment thresholds may be required for some comorbidities (e.g., cyanotic heart disease or traumatic brain injury) and age (e.g., premature infant).
c. An intracranial hemorrhage may require a higher platelet treatment threshold (<100 × 109).
d. In cardiac surgery, a higher fibrinogen dose (70 mg/kg, maximum 4 g or 2 g if less than 30 kg) and treatment threshold (less than 2.0 g/L) may be required.

Please see Figure 1 for a summary of pediatric massive hemorrhage guidelines.

Monitoring of Massive Transfusion

• Monitor shock severity and resuscitation response: Regularly check cardiovascular (pulses, heart rate, blood pressure), integumentary (capillary refill), respiratory (rate and depth), central nervous system (mental status, Glasgow coma scale, temperature), and renal (urine output) organ systems.
• Class II to class III shock transition: This transition indicates a failure of compensatory mechanisms, which is often masked in children due to their strong cardiovascular response.
• Blood, the body’s largest organ, is composed of cells, plasma, and vascular endothelium. It can fail due to hemorrhagic shock and is modulated by tissue injury.
• Blood failure is an emergency characterized by critical oxygen debt (shock), with evidence of low tissue oxygen delivery, endotheliopathy, platelet dysfunction, and coagulopathy.⁸
• Monitor blood failure: Use hemoglobin, lactate, pH, base deficit, and coagulation tests.⁹
• Viscoelastic testing in children is often underutilized due to cost and limited data on normal values and outcomes.