In this section
This guideline aims
to provide certainty for clinicians working with a critically
bleeding infant, child or adolescent. It outlines the
responsibilities of the clinical Team Leader, the circulation
nurse, Blood Bank and the Haematologist involved. It also provides
a guide for pathology testing and other assessment (temperature,
acid-base) and blood product provision.
This clinical guideline has been developed using the
Patient Blood Management Guidelines: Module 1 Critical Bleeding/ Massive Transfusion, developed by the National Blood Authority
Critical Bleeding: May be defined as a
major haemorrhage that is life threatening and likely to result in
the need for massive transfusion.
The Massive Transfusion Protocol (MTP) is in place to direct
provision of large volumes of blood product (Red Cells, Plasma and
Platelets) to a critically bleeding child.
Massive Transfusion Protocol will mobilise significant
resources and as such should be activated after considering the
WHO: MTP may be activated by the team
leader in Emergency
WHEN: MTP may be activated when it appears
likely that a child will require massive transfusion. This
can be after assessment on patient arrival or based on credible
information prior to patient arrival. It is expected that
this protocol will be activated INFREQUENTLY.
WHAT: Massive Transfusion Protocol Activation
will result in:
Send a completed Blood Bank Release Order (Green form) with a
patient bradma label via the Trauma PSA to the Blood Bank. Please
tick Massive Transfusion Pack and document the working weight in
the estimated weight space.
Receipt of a patient bradma label with a bar code allows for
rapid electronic assignment of blood product. If this isn't
available then this step will be performed manually.
Failure to do this will lead to delays in the provision of
crossmatched blood and may exhaust O negative supplies very
The Massive Transfusion Protocol is designed to ensure that when
a patient has received or is likely to receive large volumes of Red
Cell, adjunct support with clotting factors (FFP) and Platelets are
also provided to manage coagulopathy and reduce the liklihood of
Retrospective studies suggest that transfusing Plasma and
Platelets in similar ratios to Red Cells confers survival advantage
in patients with critical traumatic bleeding. Depending on
product availability the Blood Bank will work to deliver
the following products:
Due to the absence of credible evidence supporting its use,
It should only be used in a trauma patient who has ongoing
bleeding despite adequate coagulation factor support, including
normalization of fibrinogen and who is normothermic (temp>35°),
and not significantly acidotic (pH >7.15), and where there is a
reasonable expectation that the patient will survive their
Prevention of Acidemia
Use the Rapid Infuser
When the MTP is triggered a comprehensive response from the RCH
Blood Bank will begin to thaw Plasma and order further product from
The Blood Service. It is crucial that the team leader inform
the Blood Bank when the MTP is over or when the patient is
transferred. Significant wastage will result from late
communication of this information.
Nursing staff will be responsible for maintaining accurate
records of what blood products have been administered and how
much. This information will be required during the Massive
Transfusion Protocol activation period and may be requested by the
Team Leader or the On call Haemataologist.
All of the empty bags should be placed into the Red bucket with
the Rapid Infuser. The transfusion records for all of these
units should also be readily accessible at conclusion to ensure all
relevant documents are signed.
There is a trial Blood product fluid balance sheet which can be
used to record the number of mls of each type of product.
Clear communication between team members is identified as an
important component contributing to good patient
When a trauma page is initiated, it is received by the CARPS
supervisor who will allocate a
PSA to the ED Resuscitation bays. When the senior medical
staff determine that they will require blood product they will
instruct this PSA to go to the Blood Bank to collect the Massive
The Blood Bank staff will provide an estimated time for the
second Massive Transfusion Pack to be prepared.
Each activation of the MTP will be reviewed by the Haematology
and Trauma teams and adjustments made to the protocol as required
and as new evidence emerges.
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