Frimley Guidelines

Massive Haemorrhage in Adults - Summary (WPH)
Management of Life-Threatening Haemorrhage in Adults in the Emergency Department (WPH only)

Key Point

This document is a quick reference guide to massive transfusion in the Emergency Department. It is not a replacement for the full trust guideline on blood transfusion.

This is a controlled document. If you are using a printed copy, check it against the version on the intranet to ensure you are using the latest edition.

Definitions

Life-Threatening Haemorrhagebleeding more than 150ml/minute, loss of 50% blood volume in 3 hours, loss of whole blood volume in 24 hours.
Haemorrhagic shockclinically evidenced by bleeding plus any of:
HR>100, SBP <90mmHg, cool/clammy/mottled skin, prolonged central CRT, reduced GCS, oliguria, lactate >4.
Indications in TraumaMajor trauma plus 1 or more of:
haemorrhagic shock, FAST positive, penetrating wound or senior clinicians’ suspicion of ongoing bleeding and circulatory failure despite resuscitation
Indications Non-traumableeding >150ml/minute, blood loss of >1500ml, loss of 50% blood volume in 3 hours, evidence of shock despite adequate resuscitation

ACTIONS

2222 ACTIVATE CODE RED TRAUMA CALL OR MEDICAL CODE RED AND MHP

ED consultant (or Senior Registrar if Out of Hours) to Activate Code Red Trauma Call or Medical Code Red

Activate Major Haemorrhage Protocol (MHP) stating ‘UNCONTROLLED HAEMORRHAGE’ and clarify that transfusion staff understand this and will prepare FFP and platelets.

Transfusion will provide O- or O+ blood (flying squad) and FFP immediately. A full cross match will take up to an hour.

Use emergency O-/pink (female patients) or O+/blue (male patients) if required while awaiting blood products from transfusion.

Intravenous access - ideally two large bore (grey or orange) cannulas in the ACFs. If no iv access, intra-osseous can be used while establishing iv access, which may need to be a femoral CVC.

Send bloods for FBC, Clotting screen, fibrinogen, U&E and cross match and obtain a venous or arterial blood gas.

STOP THE BLEEDING e.g. external pressure/packing/tourniquets in bleeding wounds, endoscopy for GI bleeds, damage control surgery, interventional radiology

Set up rapid infuser, all massive transfusions to be given warmed via the Belmont rapid infuser

TXA in trauma if within 3 hours of injury 1g iv bolus followed by 1g iv over 8 hours OR a 2g bolus.

Reversal of warfarin with Beriplex and Vitamin K if INR more than 1.5 and life or limb threatening bleeding. This DOES NOT require consultant haematologist approval.

Reversal of DOACs - discuss with haematology

Suspected variceal bleeds - give Terlipressin 2mg iv and Ceftriaxone 2g iv

Give Calcium 30mls Calcium Gluconate 10%.

Transfusion ratios 1:1:1 RBCs:FFP:Platelets

Cryoprecipitate (2 pools) if fibrinogen <1.5.

Recombinant factor VII (Novoseven) can be of value if after the administration of 2 MHPs. Discuss with Haematology Consultant.

Transfusion Targets

HaematologicalHaemodynamicsMetabolic
Hb 80-100SBP 90-100mmHgpH >7.35
Platelets >75MAP >80mmHg if brain injuryiCa2+ >1
Fibrinogen >1.5Temperature >36
PT <1.5Potassium 4-5

Staffing

(see Appendix 2 for full list)

The team must be led by an ED consultant in hours or by a senior registrar.

1 nurse must be allocated to operating the Belmont rapid infuser. This must be their sole job during the massive transfusion.

1 member of the code red team, ideally a senior doctor, to liaise with transfusion, keep a record of products transfused and ensure correct ratios given. This is the Clinical Communication Lead (CCL).

Dedicated blood porter.

REMEMBER: EXCESSIVE TRANSFUSION WORSENS OUTCOMES