Procurement and Administration of Blood for Trauma Resuscitations

Original Date: 09/2000 | Supersedes: 04/2008, 06/2011, 10/2014 | Last Review Date: 09/2020
Purpose: To describe the process for ordering blood in the acutely injured patient.

In serological cross matching, red cells from the donor unit are tested against serum of the patient. If the patient’s serum contains antibodies against antigens present on donor red blood cells, agglutination will occur. Agglutination is considered a positive reaction indicating that the donor unit is incompatible for that specific patient. In emergency cases, the trauma team can request uncross-matched whole blood or uncross-matched blood components. It is thought that this lifesaving measure is of more benefit than any risk of an antibody-mediated transfusion reaction. In addition, the risk of a serious transfusion reaction can be minimized if the donor unit is both ABO-compatible and Rhesus (Rh)-compatible (type-specific). In an emergency, blood group type can be done easily and quickly in 2 or 3 minutes in the laboratory on glass slides with appropriate reagents, by trained technical staff. Although the transfusion of fully cross matched blood is preferable, its availability may be delayed for up to one hour. For patients who stabilize rapidly, cross-matched blood should be obtained and available if needed.

  1. A type and screen sample must be drawn immediately, labeled, placed in a red bag, and taken to the lab (Blood Bank) on all level-1 trauma activations. Personnel should go to the Blood Bank with a requisition slip to pick up type-specific blood. This blood is compatible with ABO and Rh blood types, but may be incompatible with other antibodies. Type-specific blood is preferable for patients who respond transiently to initial fluid resuscitation with balanced salt solution, but have recurrence of hypotension and tachycardia with moderate, ongoing blood loss. Completion of the cross-matching should be performed by the blood bank when type specific blood is used.
  2. Type O and Rh-negative blood can be given if the recipient’s blood group is not known, as may happen in an emergency. As such, in patients with exsanguinating hemorrhage, Type O and Rh-negative red blood cells are indicated. Four units of type O and Rh-negative blood and 2 units of whole blood are kept in the EC trauma area to expedite blood administration in these patients.
  3. For patients who are hemodynamically unstable and require blood in the EC, AB thawed plasma should be mobilized (from the same EC refrigerator) and transfused immediately.
  4. For all patients predicted or suspected of requiring substantial transfusions, the institution’s massive transfusion protocol (MTP) should be activated immediately. In addition, patient’s in whom the use of uncross-matched blood or plasma is required should also have the MTP activated immediately. Blood from the MTP will not be fully cross-matched but rather type specific. Patients likely to require MTP are those with two of the following: (1) EC arrival heart rate >120, (2) EC arrival systolic blood pressure < 90 mmHg, (3) positive FAST exam, (4) penetrating trauma mechanism, or (5) use of uncross-matched blood in EC. Using these parameters, the clinician will be correct 86% of the time with PPV of 53% and NPV of 96%. These parameters are consistent with the concept of acceptable over-triage and minimizing under-triage. Remember, the blood products can always be returned and used for another patient while not having the appropriate number and type of products when you need them can be a lethal omission.
  5. To activate the protocol, the blood bank should be called immediately at 4-3640.
    Simultaneously, the green blood requisition slip should be labeled and sent by “runner” to the Blood Bank. The requisition slip should NOT include a specific number of products once the MTP is
    activated. Rather, the letters “MTP” or the word “MASSIVE” should be written across the green requisition slip.
  6. If the patient remains unstable and it is the trauma team’s opinion that the patient cannot wait (5-10 minutes) for the release of the first box of type specific product then uncross-matched products can be released (6 units of o-negative RBC and 6 units of thawed AB plasma, plus one dose of platelets). In these situations, the team should notify the Blood Bank to immediately release products pending type and screen. If the patient’s clinical situation allows or if the Blood Bank already has run the type and screen) then the standard MTP cooler will be released with 6 units of RBC, 6 units of plasma and a dose of platelets. Please note, platelet will be sent in a separate tackle box type container and should not be refrigerated.
  7. Recommend not exceeding a rate of 75 mL/min for infusion of blood products when using the Belmont Rapid Infuser – exceeding this rate of flow will outpace the ability of the blood bank to
    resend additional MTP coolers.