Most hospitals seem to have a single MTP protocol which is used across various different contexts.MTP was designed and validated primarily for the management of traumatic hemorrhage.Worsening hypotension and vasopressor requirement should prompt consideration for MTP. Hypotension is usually a late manifestation of hemorrhage.Consequently, checking the hemoglobin has little role in determining need for MTP. The hemoglobin level takes hours to fall after bleeding.Is the patient definitely in hemorrhagic shock? (If doubt exists about whether the patient is in hemorrhagic shock, echocardiography may be useful to confirm the presence of hypovolemia.). What is the expected trajectory of this type of bleeding?.Ultimately, initiation of a massive transfusion protocol is based on clinical judgement, considering the following factors: There are no simple criteria for this.When should the massive transfusion protocol be initiated? Traditional labs generally won't return fast enough to guide the use of clotting factors, so this is protocoled (example below). Massive transfusion protocols involve the use of balanced transfusion (including PRBCs and clotting factors), in efforts to avoid dilutional coagulopathy.Hypocalcemia-induced coagulopathy (due to citrate in blood products).Hypothermia from transfusion of cold products.Dilution of clotting factors (including platelets and fibrinogen).Patients with severe hemorrhage may develop refractory hemorrhage due to a collection of factors:.Introduction to massive transfusion protocol (MTP)Ĭoncept of a massive transfusion protocol (MTP) Stop MTP when patient is hemodynamically stable.Target lower than typical MAP, pending source control.Follow temperature, consider pre-emptive warming (e.g., with heated air blankets).For intubated patients, adjust ventilator to optimize pH.Review anticoagulant medications & consider reversal Consider in renal failure, thrombocytopenia, or antiplatelet drugs.May continue infusion at a rate of 1 gram over 8 hours – especially in obstetric or early traumatic hemorrhage.Consider 1 gram IV, if difficulty achieving hemostasis.Follow iCa if possible, target normal to mildly elevated iCa (e.g., ~1-3 mM).1-2 gram Ca chloride or 3-6 grams Ca gluconate per MTP round (6 units PRBC).Fibrinogen may be especially important in obstetric hemorrhage.Consider 1:1:1:1 ratio of PRBC : FFP : Platelets : Cryo.Designate a specific person to call the blood bank immediately.Ĭonsider additional fibrinogen (e.g., cryoprecipitate) □.Triggers for initiation & termination are clinical.VBG or ABG if concern for significant acidemia.Īctivate MTP and communicate with blood bank.Electrolytes, Ca/Mg/Phos, ionized calcium.CBC, INR, PT, PTT, fibrinogen (TEG if available).Massive Transfusion Protocol Checklist ✅ labs (order them, but don't delay treatment while you wait)
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