| Scoring System | Criteria | Threshold |
|---|---|---|
| ABC Score | Penetrating mechanism (+1), SBP ≤ 90 (+1), HR ≥ 120 (+1), positive FAST (+1) | ≥ 2 activates MTP |
| Shock Index | HR / SBP | > 1.0 predicts need for MTP |
| Clinical Triggers | Obvious massive hemorrhage, hemodynamic instability unresponsive to 2L crystalloid | Clinical judgment |
| Quantitative | ≥ 4 units pRBC in 1 hour with ongoing bleeding, OR anticipated need for ≥ 10 units pRBC in 24h | Volume-based |
| Component | Mechanism | Prevention/Treatment |
|---|---|---|
| Hypothermia | Core temp < 35°C impairs coagulation enzyme kinetics, platelet function, and fibrinolysis | Warm all products via rapid infuser, forced-air warming blanket, warm OR/room, warm IV fluids. Target temp > 36°C |
| Acidosis | Hemorrhagic shock → tissue hypoperfusion → lactic acidosis. pH < 7.2 severely impairs clotting factor function | Restore perfusion with blood products (not crystalloid). Limit NS (hyperchloremic acidosis). Bicarb if pH < 7.1 |
| Coagulopathy | Dilutional (crystalloid), consumptive (ongoing hemorrhage), and dysfunction (hypothermia + acidosis impair cascade) | 1:1:1 balanced resuscitation, cryo for fibrinogen < 150, TXA, avoid excess crystalloid |
| Product | Ratio | Key Notes |
|---|---|---|
| pRBCs | 1 | O-neg until type & screen available (O-pos acceptable for males) |
| FFP | 1 | Replaces clotting factors. Thaw takes 20โ30 min -keep thawed plasma available |
| Platelets | 1 | 1 apheresis unit per 6-pack pRBC |
| Cryoprecipitate | Give when fibrinogen < 150 | 10 units = โ fibrinogen ~70 mg/dL |
| TEG Parameter | ROTEM Equivalent | What It Measures | Abnormal → Treatment |
|---|---|---|---|
| R time | CT (clotting time) | Time to initial fibrin formation (factor activity) | Prolonged → FFP |
| K time / Alpha angle | CFT / Alpha angle | Speed of clot strengthening (fibrinogen) | Prolonged K / low alpha → Cryoprecipitate |
| MA (max amplitude) | MCF (max clot firmness) | Clot strength (platelet + fibrinogen) | Low MA → Platelets (if fibrinogen adequate) |
| LY30 | ML (max lysis) | Fibrinolysis at 30 min | LY30 > 3% → TXA (hyperfibrinolysis) |
| Product | Dose | Route | Notes |
|---|---|---|---|
| Calcium Chloride | 1g (10 mL of 10%) per 4 units pRBC | Central line preferred | 3x more elemental Ca than gluconate. Extravasation causes tissue necrosis |
| Calcium Gluconate | 3g IV per 4 units pRBC | Peripheral or central | Safer peripherally. Requires hepatic metabolism to release ionized Ca |
| TRALI | TACO | |
|---|---|---|
| Mechanism | Donor anti-HLA / anti-HNA antibodies activate recipient neutrophils โ non-cardiogenic pulmonary edema (capillary leak) | Volume overload from rapid or large-volume transfusion in patient with limited cardiac reserve |
| Onset | Within 6 hours of transfusion (typically < 2h) | Within 6 hours of transfusion, often during or just after |
| Risk factors | Multiparous female donors (anti-HLA in donor), critically ill recipient, sepsis, recent surgery | Elderly, CHF, renal failure, rapid transfusion rate, pediatrics, > 6 units pRBC |
| Vital signs | Hypotension, fever, tachycardia, hypoxemia | Hypertension, tachycardia, hypoxemia, JVD |
| BNP / NT-proBNP | Normal or low (not cardiac in origin) | Elevated (volume-mediated) |
| CXR | Bilateral infiltrates, looks like ARDS, no cardiomegaly | Bilateral infiltrates with cardiomegaly, Kerley B lines, pleural effusions |
| Echo | Preserved EF, no chamber enlargement | Systolic or diastolic dysfunction, dilated chambers |
| Treatment | Stop transfusion. Supportive ARDS care: lung-protective ventilation, conservative fluids. Diuretics not helpful (and harmful if hypotensive). Corticosteroids unproven. | Stop transfusion. Diuretics (furosemide 20โ40 mg IV). Sit patient up. Slow transfusion rate; smaller aliquots (250 mL increments). |
| Mortality | ~5โ10% in MTP setting; some studies up to 20% | Lower (~1โ2%), more amenable to volume removal |
| Anticoagulant | Reversal Agent | Dose | Notes |
|---|---|---|---|
| Apixaban (Eliquis), rivaroxaban (Xarelto) | Andexanet alfa (Andexxa) | Low-dose: 400 mg bolus + 4 mg/min ร 120 min. High-dose: 800 mg bolus + 8 mg/min ร 120 min (if last dose > 5 mg apixaban or > 10 mg rivaroxaban within 8h) | Specific factor Xa decoy. Expensive (~$50,000/dose). Increased thromboembolism post-reversal, balance against benefit. ANNEXA-4 / ANNEXA-I |
| Dabigatran (Pradaxa) | Idarucizumab (Praxbind) | 5 g IV (two 2.5 g vials) over 5โ10 min | Specific Fab fragment. Rapid (< 5 min onset). Re-elevation of dabigatran possible at 12โ24h, can re-dose. REVERSE-AD, 2017 |
| Warfarin (Coumadin) | 4-factor PCC (Kcentra) + vitamin K | 4F-PCC: 25โ50 units/kg IV (INR-based; max 5000 units). Vitamin K: 10 mg IV over 30 min | 4F-PCC for emergent reversal (faster than FFP, lower volume, better outcomes). Vitamin K for sustained reversal (4F-PCC is short-acting, INR rebounds without K). Sarode, 2013 |
| UFH (heparin) | Protamine sulfate | 1 mg IV per 100 units of heparin given in last 2โ3h (max 50 mg). Slow IV push over 10 min. | Watch for anaphylaxis (especially fish allergy, prior protamine, NPH insulin users), hypotension, paradoxical anticoagulant effect at high doses. |
| LMWH (enoxaparin) | Protamine sulfate (partial reversal only) | 1 mg per 1 mg enoxaparin if given within 8h (~60% efficacy). 0.5 mg per 1 mg enoxaparin if 8โ12h. | Only ~60% reversal at best (protamine binds anti-IIa activity but only partially anti-Xa). Andexanet has been studied but is NOT FDA approved for LMWH. |
| Antiplatelets (ASA, clopidogrel, ticagrelor, prasugrel) | Platelet transfusion + desmopressin (DDAVP) | Platelets: 1 apheresis unit (or 6-pack random donor). DDAVP: 0.3 mcg/kg IV (max 20 mcg). | Controversial in spontaneous ICH (PATCH, 2016 showed harm in non-surgical ICH), but standard practice in MTP and emergent neurosurgery. DDAVP releases vWF and improves platelet adhesion. |
| Fondaparinux | No specific reversal | 4F-PCC 50 units/kg or rFVIIa 90 mcg/kg as last resort | Off-label, mixed evidence. No FDA-approved specific reversal exists. Half-life 17โ21h; supportive care often required. |
| Drug | Dose | Indication |
|---|---|---|
| Tranexamic Acid (TXA) | 1g IV bolus โ 1g over 8h | Antifibrinolytic -give within 3h of injury |
| Calcium Chloride | 1g IV per 4 units pRBC | Prevent/treat citrate-induced hypocalcemia |
| Calcium Gluconate | 3g IV (equivalent to 1g CaCl) | Alternative if no central line (less tissue necrosis) |
| Cryoprecipitate | 10 units IV | Fibrinogen < 150 mg/dL |
| Vitamin K (Phytonadione) | 10 mg IV | If on warfarin or INR > 1.5 |
Patient: 28M restrained driver, high-speed MVC. GCS 14, HR 132, BP 78/50, RR 24. FAST positive. Pelvis unstable.
Assessment: ABC Score = 3 (SBP ≤ 90, HR ≥ 120, FAST+). Shock Index 1.7. Activate MTP.
Management:
Key lesson: Activate MTP early on clinical criteria. Use TEG to guide products once initial resuscitation underway.
Patient: 62M, cirrhosis (MELD 24), large-volume hematemesis. HR 128, BP 82/48, lactate 7.2. INR 2.8, plt 52, fibrinogen 88.
Assessment: Massive upper GI bleed with baseline coagulopathy. Shock Index 1.6.
Management:
Key lesson: Cirrhotic patients need aggressive fibrinogen replacement. Transfuse to Hgb 7–8 (overtransfusion ↑ portal pressure). Early endoscopy is critical.
Patient: 32F, G3P3, vaginal delivery 45 min ago. EBL 2L, ongoing. HR 138, BP 74/42, AMS. Boggy uterus.
Assessment: PPH from uterine atony. Hemorrhagic shock. Shock Index 1.9.
Management:
Key lesson: PPH is #1 cause of maternal death. Uterotonics first (atony is #1 cause). TXA early (WOMAN trial). Young patients compensate until sudden collapse.