Adult Massive Transfusion Protocol

Original Date: 12/2005 | Last Review Date: 05/2024
Purpose: To describe the process of ordering and providing blood and blood components to acutely injured patients.

Overview:

  • The goal of the Massive Transfusion Protocol (MTP) is to ensure balanced resuscitation with a transfusion ratio of 1:1:1 (plasma: platelets: RBCs) starting with the first units transfused.
  • For all patients predicted or suspected of requiring substantial transfusions or in whom the use of uncross-matched blood products are required, MTP should be activated immediately.
  • Patients receiving blood products prehospital will automatically have MTP activated.
    • Personnel will be sent to retrieve an MTP cooler when a “LEVEL 1 WITH BLOOD” or similar page is sent.
  • “LifeFlight to OR” and “Ground EMS to OR” activations will also automatically have MTP activated.
    • Blood procurement procedural details are stipulated in the respective activation protocols.
  • Patients likely to require MTP are those with two of the following:
    • EC arrival heart rate >120
    • EC arrival systolic blood pressure < 90 mmHg
    • Positive FAST exam
    • Penetrating trauma mechanism
    • Use of uncross-matched blood in EC
  • Using these parameters, the clinician will be correct 86% of the time (PPV 53%, NPV 96%). This is consistent with the concept of acceptable over-triage and minimizing under-triage.
  • Remember: blood products can always be returned and used for another patient but not having the appropriate number/type of products can be a lethal omission.

Massive Transfusion Protocol:

  • To activate MTP, the blood bank should be called immediately at 4-3640. Simultaneously, the green blood requisition slip should be “MTP” or “MASSIVE” and sent by a runner to the Blood Bank.
    • The requisition slip should NOT include a specific number of products once the MTP is activated.
  • The following laboratory tests should be drawn for every Level 1 trauma immediately upon arrival (as soon as clinically possible) and then as clinically indicated:
    • Type and Screen, CBC, rapid TEG and ABG/VBG.
    • Prioritize the patient’s first blood draw as a Type and Screen for Blood Bank so that universal blood products can be transitioned to type-specific (not fully cross-matched) products as early in the resuscitation as possible. This reduces antibody formation and conserves universal products. This should go to the blood bank immediately after being drawn.
  • The initial MTP cooler will contain 6 units packed RBCs, 6 units of plasma and 1 dose of platelets.
    • 1 jumbo plasma = 2 to 3 regular plasma units
    • 1 “dose” of platelets = 5 pooled random-donor platelet units or 1 apheresis platelet unit
  • For MTP activations prior to patient arrival or when patients are hemodynamically unstable and it is the Trauma Team’s opinion that the patient cannot wait for the release of the first cooler of type specific product, then uncross-matched products can be released. This initial MTP release will include: 6 units of O-negative (female)/O-positive (male) RBC and 6 units of thawed or liquid group A (low anti-B antibody titer) plasma).
    • In these situations, the team should notify the Blood Bank to immediately release products pending type and screen.
  • After the first cooler leaves the Blood Bank, a component order will be prepared and be available within 5-10 minutes.
    • Component order:  6 RBCs and 6 plasma (or 2-3 jumbo plasma) and 1 platelet dose.
      • 1 dose of platelets will be issued with every 6 units of RBCs and 6 units of plasma.
      • This platelet dose will be repeated after every 6 additional RBCs issued.
    • If patient’s blood type is known and is group O, the Blood Bank may release whole blood units instead of component therapy. These coolers may contain 4-6 units of whole blood and no components or separate tackle box of platelets.
    • Requests for components exceeding this protocol, as well as cryoprecipitate, may be made at any time by direct notification of Blood Bank (4-3640).
    • No blood components will be issued without a pickup slip with the recipient’s medical record number and name.
  • Subsequent coolers can be adjusted or modified based on the following rapid TEG values:
    • ACT > 128 Transfuse plasma and RBC
      r-value > 1.1 Transfuse plasma and RBC
      k-time > 2.5 Transfuse plasma
      Add cryoprecipitate/fibrinogen if angle also abnormal
      a-angle < 60 Transfuse cryoprecipitate (or fibrinogen)
      Add platelets if mA is also abnormal
      MA < 55 Transfuse platelets
      Add cryoprecipitate/fibrinogen if angle also abnormal
      LY-30 > 3% Administer tranexamic acid or aminocaproic acid
  • This process will automatically be repeated each time the set of components is issued until the attending Trauma Surgeon, Anesthesiologist, or Circulator Nurse notifies the Blood Bank that the MTP is no longer needed.
    • Until then, blood coolers should follow the patient at all times to prevent duplicate blood orders and unavailability of blood when needed by the patient.
  • When done with the operative case and/or massive transfusion, please contact the Blood Bank to stop the MTP. The phone call can be made by trauma faculty, anesthesia faculty, or a circulator nurse. At this time, unused products should be returned to the Blood Bank unless planned for immediate transfusion.