Page 1 of 14
Guidelines and Protocols
Lyndon B. Johnson General Hospital Trauma Services
Department
Guideline/Protocol Number: T3
TITLE: MASSIVE TRANSFUSION PROTOCOL
PURPOSE:
To establish a transfusion protocol for Harris Health System patients whose blood
loss necessitates emergent release of large volumes of Blood Products.
PROCESS:
The Massive Transfusion Protocol (MTP) is to be activated by on-site faculty
members from the Emergency Department, Trauma Team, ICU, OB, and/or the
Anesthesia/OR/ Teams. The initiating team must notify the Blood Bank immediately
(713-566-5293; x65293) of the need for MTP.
Initiation of the MTP consists of a two-step process which includes:
1. Communication, either in EPIC (using the MTP order-set), or an Emergency
Blood Request Form. The order-set instructs the provider to call Blood Bank
and the order will print out in Blood Bank.
The documentation must include the following information:
a. Valid patient information (Name and medical record number, or a
uniquely assigned number i.e. temporary unknown name/number)
b. Name and ID number of requesting physician
c. The statement “Massive Transfusion (or “MTP”) is requested.”
2. Verbal initiation by a member of the initiating team to a member of the Blood
Bank staff by telephone (x65293) or in-person is acceptable as long as the
necessary written documentation is provided and the clinical situation allows.
Page 2 of 14
Guidelines and Protocols
Lyndon B. Johnson General Hospital Trauma Services
Department
Guideline/Protocol Number: T3
Red blood cells (RBC’s) will be issued as follows, unless requested differently by the
initiating team:
1. O-negative/O-positive, uncross matched RBC’s (available immediately
in EC or Blood Bank)
2. O-negative, uncross matched RBC’s should be used in pregnant women
(available immediately in L&D)
3. Type-specific, uncross matched RBC’s (available within 5-10 minutes of
receipt of a properly labeled patient sample)
4. Type-specific, crossmatch-compatible units (available within 45-60
minutes of receipt of a properly labeled patient sample)
Please note that full, pre-transfusion testing will begin upon receipt of a properly
labeled patient sample and will be used to guide subsequent product release as results
become available.
Please note that additional processing (irradiation, antigen-negative units, volume
reduction, etc.) will not be performed while MTP is in progress.
The initiating team will be notified when full cross match is complete. Type-specific,
cross match-compatible units will be traded out for any remaining uncross-matched
blood.
Additional staff will be utilized from other areas of the Laboratory to maintain
continual Blood Bank support. If the patient is unable to be supported adequately
with the MTP protocol, or the hospital blood supply is compromised, a decision must
be made by the initiating team as to alternate patient options.
Page 3 of 14
Guidelines and Protocols
Lyndon B. Johnson General Hospital Trauma Services
Department
Guideline/Protocol Number: T3
I. PROCEDURE
a. A blood sample may be submitted with a printed EPIC label (per system
labeling policy) the EPIC system captures date/time/collection info
If there is not an EPIC label available, the sample should be submitted
with name/medical record number/time/collector’s ID written on chart and
downtime label
b. A completed form (or verbal initiation as described above) must be
provided with the patient’s name and number, the signature of the
requesting physician/designee, and taken by a designated transporter to
the Blood Bank. Units will not be issued without a medical record
number.
c. Within 5-10 minutes of receipt of a “Massive Transfusion Protocol”
directive, the Blood Bank will have a prepared cooler containing 4 units
of RBCs, 4 units of type-compatible fresh frozen plasma (FFP), and 1
apheresis unit of platelets (4:4:1). For OB patients a unit of
cryoprecipitate will be included in the initial prepared cooler.
i. If 4 type-compatible FFP units are not immediately available
(based upon the blood type of the patient and Blood Bank
inventory), the Blood Bank will issue any available units and notify
the initiating team when the remaining units are available.
ii. Initiate process to order additional blood products from blood
supplier as needed.
d. The Blood Bank will inform the lab staff of MTP initiation, lab staff will
start TEG controls. The Blood Bank staff will notify the Pathologist that
the MTP has been initiated. The Pathologist will initiate contact with
the responsible service for consult as needed.
e. With each instance of component issue, a Blood Issue Slip must be
utilized to confirm patient identity.
Page 4 of 14
Guidelines and Protocols
Lyndon B. Johnson General Hospital Trauma Services
Department
Guideline/Protocol Number: T3
f. After the initial 4 RBCs, 4 FFP, and 1 unit of platelets have been issued,
the Blood Bank will prepare an additional 4 RBCs, an additional
apheresis unit of platelets, and initiate the thawing of 4 additional type-
compatible FFP units.
g. This process will be automatically repeated until the Blood Bank is
informed by a member of the current clinical team that the MTP is no
longer needed.
h. The initiating team will order the following laboratory tests as clinically
indicated:
i. Fibrinogen to determine if cryoprecipitate is needed (see Empiric
Guidelines below)
ii. TEG to assess for coagulopathy, platelet dysfunction, and
fibrinolysis
i. Blood Products (with the exception of platelets and cryoprecipitate) may
be maintained in an assigned Blood Bank cooler for a maximum of 4
hours. After 4 hours have elapsed, the cooler must be returned to the
Blood Bank for a current temperature check, and installation of new ice
blocks.
j. Continual contact will be maintained between the Blood Bank and the
blood supplier to ensure uninterrupted component supply.
k. Upon hemorrhage control and hemodynamic stability, the clinical team
will notify Blood Bank to discontinue MTP.
Page 5 of 14
Guidelines and Protocols
Lyndon B. Johnson General Hospital Trauma Services
Department
Guideline/Protocol Number: T3
II. EMPIRIC GUIDELINES FOR MASSIVE TRANSFUSION
FFP
For every 4 RBCs, give 4 FFP (1:1 ratio)
Platelets
For every 4 RBCs, give 1 apheresis unit of platelets.
Cryoprecipitate
After first 12 to 16 RBCs, check fibrinogen level.
If <100 mg/dL, give 10 units cryoprecipitate. Repeat as needed, depending on fibrinogen level, and request appropriate amount of cryo.
NOTE: FFP also contains fibrinogen.
For OB-GYN Patients: Administration of cryoprecipitate with first series of
RBC’s and FFP is recommended.
Page 6 of 14
Guidelines and Protocols
Lyndon B. Johnson General Hospital Trauma Services
Department
Guideline/Protocol Number: T3
APPENDIX A: MTP ALGORITHM
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Guidelines and Protocols
Lyndon B. Johnson General Hospital Trauma Services
Department
Guideline/Protocol Number: T3
Stage 1: Blood loss >1000 mL after delivery with normal vital signs and lab
values. Vaginal delivery 500-999mL should be treated as in Stage 1.
APPENDIX B: OB HEMORRHAGE CHECKLIST
Obstetric Hemorrhage Checklist
Complete all steps in prior stages plus current stage regardless of stage in which the patient
presents
Recognize, call for assistance: □ Obstetric Hemorrhage Team
Designate: □ Team lead □ Checklist reader/recorder □ 2nd RN
Announce: □ Cumulative blood loss □ Vital signs □ Determine Stage
Initial Steps:
Ensure 16G or 18G IV Access
Insert indwelling urinary catheter
Fundal massage
Vital Signs Q 5 minutes
Medications:
Increase oxytocin rate
Administer appropriate medications, consider patient
history
Blood Bank:
Type and Crossmatch 2 units RBCs
Action:
PPH Kit
QBL assessed, announced and recorded q 15 minutes
Determine etiology and treat
Prepare OR, if clinically indicated
(Optimize visualization/examination)
Medications:
Oxytocin (Pitocin):
30 units per 500 mL solution
Methylergonovine (Methergine):
0.2 milligrams IM q 2 – 4 hours;
Avoid with hypertension
15-methyl PGF₂α (Hemabate, Carboprost):
250 micrograms IM (may repeat in q15 minutes,
maximum 8 doses); Avoid with asthma
Misoprostol (Cytotec):
800 micrograms PR (max dose)
600 micrograms buccal (max dose)
Tranexamic Acid (TXA): I gram IVPB over 10
minutes; may be repeated once after 30 min
Tone (i.e. atony)
Trauma (i.e. laceration)
Tissue (i.e. retained products)
Thrombin (i.e. coagulation dysfunction)
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Guidelines and Protocols
Lyndon B. Johnson General Hospital Trauma Services
Department
Guideline/Protocol Number: T3
Stage 2: Continued Bleeding (Blood loss up to 1500mL OR > 2
uterotonics) with normal vital signs and lab values
Huddle and move to Stage 3 if continued blood loss and/or abnormal VS
Initial Steps:
Activate OB Emergency
Place 2nd IV (16-18G)
Draw Labs (CBC, PT/PTT, INR, Fibrinogen, TEG)
Prepare OR
Medications:
Continue Stage 1 medications
Blood Bank:
Obtain 2 units RBCs (DO NOT wait for lab results. Transfuse per clinical signs/symptoms)
Action:
Consider moving patient to OR
Consider possible interventions
Initial Steps:
Mobilize additional help: Notify Trauma when at LBJ
Move to OR
Announce clinical status:
(vital signs, cumulative blood loss, etiology)
Draw Labs:
(CBC, Pt/PTT, INR, Fibrinogen, TEG)
Outline and communicate plan
Blood Bank:
Consider Initiating Massive Transfusion Protocol: State “Obstetric Patient”
Consult Trauma when at LBJ
Medications:
Continue Stage 1 Medications
Administer Transexemic Acid (TXA) 1 gram IVPB; if bleeding persists, administer
second dose of 1 gram TXA IVPB
Re-Dose Antibiotics
Possible Interventions:
Bakri Balloon
Compression suture/B-Lynch suture
Uterine artery ligation
Hysterectomy
Stage 3: Continued Bleeding (EBL >1500mL and >2RBCs given OR at risk
for occult bleeding/coagulopathy OR any patient with abnormal vital
signs/labs/oliguria)
Possible Interventions:
Bakri Balloon
Compression suture/B-Lynch suture
Uterine artery ligation
Hysterectomy
Page 9 of 14
Guidelines and Protocols
Lyndon B. Johnson General Hospital Trauma Services
Department
Guideline/Protocol Number: T3
Action:
Draw Labs (CBC, PT/PTT, INR, Fibrinogen; Blood Gas; TEG)
Consider etiology for appropriate interventions
Escalate Interventions
If continued bleeding is >2000mL; Massive Transfusion Protocol MUST be initiated
Initial Steps:
Mobilize additional resources
Medications:
ACLS
Blood Bank:
Continue Massive Transfusion Protocol
Action:
Immediate surgical intervention to ensure
Stage 4: Cardiovascular Collapse (massive hemorrhage, profound hypovolemic
shock, or amniotic fluid embolism)
Page 10 of 14
Guidelines and Protocols
Lyndon B. Johnson General Hospital Trauma Services
Department
Guideline/Protocol Number: T3
Appendix C: Massive Transfusion EPIC Order Set QRG
Page 11 of 14
Guidelines and Protocols
Lyndon B. Johnson General Hospital Trauma Services
Department
Guideline/Protocol Number: T3
Page 12 of 14
Guidelines and Protocols
Lyndon B. Johnson General Hospital Trauma Services
Department
Guideline/Protocol Number: T3
Page 13 of 14
Guidelines and Protocols
Lyndon B. Johnson General Hospital Trauma Services
Department
Guideline/Protocol Number: T3
Page 14 of 14
Guidelines and Protocols
Lyndon B. Johnson General Hospital Trauma Services
Department
Guideline/Protocol Number: T3
REFERENCE / BIBLIOGRAPHY:
OFFICE OF PRIMARY RESPONSIBILITY:
LYNDON B. JOHNSON HOSPITAL TRAUMA SERVICES
REVIEW / REVISION HISTORY
Effective Date Version #
(If Applicable)
Review/ Revision Date (Indicate Reviewed or Revised) Approved by:
10/20/20 10 10/20/2020 Trauma Committee
06/16/20 9 06/16/20 Trauma Committee
05/16/17 8 05/16/17 Trauma Committee
05/19/15 7 05/19/15 Trauma Committee
10/21/14 6 10/21/14 Trauma Committee
10/16/12 5 10/16/12 Trauma Committee
06/19/12 4 06/19/12 Trauma Committee
09/23/11 3 09/23/11 Trauma Committee
09/15/08 2 09/15/08 Trauma Services