Activate the massive haemorrhage protocol early. Give tranexamic acid 1 g early (within 3 h of trauma) unless contraindicated. Keep the patient warm and correct ionised calcium: beat the lethal triad of hypothermia, acidosis and coagulopathy.
Activate when
- Expected or ongoing major blood loss
- Loss of one blood volume or more likely
- Uncontrolled surgical or traumatic bleeding
- Shock not responding to the first unit
Immediate actions
- Two large-bore cannulae, cell salvage if available
- Group O (O negative for women of child-bearing potential) until crossmatch ready
- Warm all fluids and blood; use a rapid warmer
- TXA 1 g over 10 min then 1 g over 8 h
Significant bleeding
- Ongoing loss, responds to fluids
- TXA 1 g, warm fluids
- Crossmatch, call blood bank
Massive haemorrhage
- One blood volume or shock
- Activate MHP, balanced 1:1
- O negative until crossmatch ready
Lethal triad / arrest
- Hypothermia, acidosis, coagulopathy
- Correct calcium, keep above 36 C
- Damage-control surgery or IR now
Balanced transfusion
1
1. Call MHP
Declare early. Assign roles: team leader, anaesthesia, surgery, a runner, and a dedicated link to blood bank.
Declare early. Assign roles: team leader, anaesthesia, surgery, a runner, and a dedicated link to blood bank.
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2
2. Products
Red cells with plasma in a balanced ratio (around 1:1). Platelets to keep above 50. Fibrinogen (cryoprecipitate or concentrate) if below 1.5 g/L (below 2 in obstetric bleeding).
Red cells with plasma in a balanced ratio (around 1:1). Platelets to keep above 50. Fibrinogen (cryoprecipitate or concentrate) if below 1.5 g/L (below 2 in obstetric bleeding).
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3
3. Monitor and correct
ABG, Hb, ionised calcium, lactate, temperature, and viscoelastic testing (ROTEM or TEG) if available. Replace calcium; keep temperature above 36 C.
ABG, Hb, ionised calcium, lactate, temperature, and viscoelastic testing (ROTEM or TEG) if available. Replace calcium; keep temperature above 36 C.
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4
4. Stop bleeding
Definitive surgical haemostasis, pelvic binder or packing, and interventional radiology. Resuscitation buys time but does not replace source control.
Definitive surgical haemostasis, pelvic binder or packing, and interventional radiology. Resuscitation buys time but does not replace source control.
| Parameter | Aim |
|---|---|
| Ionised calcium | Above 1.1 to 1.2 mmol/L |
| Fibrinogen | Above 1.5 g/L (2 in obstetrics) |
| Platelets | Above 50 |
| Temperature | Above 36 C |
Calcium
- Citrate in stored blood chelates calcium and lowers ionised Ca
- Replace guided by ionised calcium and haemodynamics
Pitfalls
- A cold, acidotic patient (worsens coagulopathy)
- Under-transfusing plasma and fibrinogen
- Forgetting TXA when eligible
- Resuscitating without arranging source control
MedPrep - www.medprep.uk - Educational revision aid only. Not clinical guidance. Doses are adult examples; check the BNF, current guidelines and local policy, and seek senior advice. Nov 2026