The MHP is appropriately triggered when a patient is massively bleeding, requiring red blood cells (RBCs) AND other components, such as plasma and platelets. Do NOT call an MHP if you only need unmatched RBCs.
References:
Patient outcomes are dependent on the quality of care provided by a high-performing interdisciplinary team including: physicians in emergency medicine, trauma, anesthesia, hematology/transfusion medicine, critical care, obstetrics; nurses; laboratorians in core laboratory and transfusion medicine; respiratory therapists; patient support workers; and porters.
References:
Tranexamic acid (TXA) is an anti-fibrinolytic drug and should be administered as soon as possible.
None of these dosing options have been compared head-to-head
References:
The patient should have blood testing upon initiation of the MHP and then repeated at least hourly thereafter.
Having access to the most up-to-date laboratory results allows for more effective resuscitation and may improve patient outcomes.
Ensure correct blood work is drawn at the beginning of MHP and repeated hourly.
References:
Aim to maintain minimum lab-based resuscitation targets:
Targets |
Hemoglobin >80 g/L |
INR <1.8 |
Fibrinogen >1.5 g/L |
Platelets >50 x109/L |
Calcium >1.15 mM |
Treatment |
RBCs |
Frozen Plasma (FP) or Prothrombin Complex Concentrates (PCCs) |
Fibrinogen Concentrate (FC) |
Platelets |
Calcium |
Recommended Resuscitation Targets |
Ontario Regional 2019 MHP |
European 2019 Guideline |
World Federation of Societies of Anaesthesiologists (WFSA) 2012 Guideline |
Hemoglobin |
>80 g/L |
70-90 g/L |
>80 g/L |
INR |
<1.8 |
<1.5 |
<1.5 |
Fibrinogen |
>1.5 g/L |
>1.5-2 g/L |
>1.0 g/L |
Platelets |
>50 x109/L |
>50 x109/L; >100 x109/L if ongoing bleeding and/or TBI |
>75 x109/L; >100 x109/L if multiple high-energy trauma, CNS injury, and/or platelet function abnormality |
Calcium |
>1.15 mmol/L |
>1.1 mmol/L |
>1.13 mmol/L |
Standard approach to blood component delivery is applicable to most large adult hospitals:
Blood Pack |
Standard Approach |
Modifications for Smaller Centres |
Box 1 |
4 RBCs |
4 RBCs |
Box 2 |
4 RBCs, 4 FP |
4 RBCs, 2000 IU PCCs, 4 g FC |
Box 3 |
4 RBCs, 2 FP, 4 g FC |
4 RBCs, 2000 IU PCCs, 4 g FC |
|
PLTs should be transfused based on count (recent guidelines suggest this is preferable to empiric transfusion) |
If no PLTs, order from Canadian Blood Services (CBS) |
Other transfusion considerations:
Potential risks of transfusion should be discussed
References:
Hypothermia is common in both traumatic injury and other patient populations with major bleeding (e.g., postpartum hemorrhage) and is associated with worse outcomes. Hypothermia causes patient discomfort and hypotension, and increases blood loss.
All patients should receive interventions to prevent hypothermia. Warming of patients improves their comfort and, even in the absence of a confirmed survival benefit, it should be a core part of every MHP.
References:
Once bleeding is under control, terminate MHP.
Quality metrics should be tracked over all activations of the MHP.
Example Set of Quality Metrics |
|
|
|
|
|
|
|
|
Regular simulations increases team building and non-technical skills in trauma
References:
A practical, evidence-based guide for front-line physicians on how to treat acquired bleeding