Attending or designee activates the Massive Transfusion Protocol (MTP) by calling the

blood bank. If the patient’s medical record number (MRN) is available, it should be given
to the blood bank staff during this phone call, otherwise it MUST accompany the staff
that picks up the first delivery.

Blood bank begins preparation of Delivery #1 immediately with the goal that it is
packaged and ready to be handed to the staff at the time of pickup.

The treating team will send staff to pick up each delivery. This staff member need not be
a physician, but can be any staff member with a EHC ID so long as they have a physician
or licensed independent practitioner (LIP)-signed massive transfusion form with them
that includes the patient name, MRN, age, and sex (preferably with a patient sticker). A
new MTP form is needed for each pickup.

The treating team should make every effort to have at least one and preferably two type
and screen specimens drawn as soon as possible. If at all possible, these sample(s) should
accompany the staff member who is picking up delivery #1. Plasma will not be thawed
until a sample is available.

At some point in the patient’s treatment course, the attending physician or designee will
call blood bank and tell them to “trigger part two.” This will trigger preparation of the
second delivery. Four units of Plasma will be placed in the thawing bath and the rest of
delivery # 2 will be prepared. In some patients this will occur during the initial call to
activate the MTP (e.g. a patient in traumatic arrest or peri-arrest). In other patients, the
team may wait to see the response to delivery #1 before triggering part two.

If the patient already has packed red blood cells available (e.g. a Surgery or OB/Gyn
patient in the operating room with type and crossed units in the OR refrigerator), the
treatment team may skip delivery 1 and immediately “trigger” delivery two.

Once part II is triggered, the MTP dictates that as soon as a delivery is picked up, the next
one will be prepared by the blood bank staff. This will continue until the MTP is
cancelled by the attending physician or designee. In some cases during rapid use of
products and since Plasma currently takes ~ 30 minutes to thaw, the blood bank should
already be thawing Plasma for future deliveries based on the speed of pick-ups and
communication with the clinicians.

If Plasma is not already thawed at the time of the second delivery, 1 bottle of PCC may
be substituted. If PCC is used, Plasma should still be thawed to prepare for subsequent
deliveries.

Blood Bank will continue to prepare shipment packs # 2-7 as described below until
notified that MTP has been discontinued. If more than 7 deliveries are needed, then the
protocol should start again at delivery # 3. All unused blood products are returned to the
Blood Bank as soon as possible.

Revision 10/3/2010 Page 1 of 4

All products should be transfused with a Hotline or Level I device if possible.

Deliveries
 One 4 Units PRBC
 Two 4 Units PRBC, 4 Units Plasma
 Three 4 Units PRBC, 4 Units Plasma, 1 Donor Pack Platelets
 Four 4 Units PRBC, 4 Units Plasma, 10 units Cryoprecipitate
 Five 4 Units PRBC, 4 Units Plasma
 Six 4 Units PRBC, 4 Units Plasma, 1 Donor Pack Platelets
 Seven 4 Units PRBC, 4 Units Plasma, 10 units Cryoprecipitate
(If units are required past delivery 7, start back at delivery 3)

Note: Plasma can refer to FFP, FP24, or Thawed Plasma

Revision 10/3/2010 Page 2 of 4

Primary Indications
 Adult patients requiring > 4 units of PRBCs in first hour of resuscitation (In other
words, patients who still need further resuscitation after Part I of the EHC
Massive Transfusion Protocol)

 Adult patients who in the Attending’s opinion, have a high likelihood of requiring
transfusion of >10 units of PRBCs within the first 12-24 hours of resuscitation.
Examples of these patients include, but are not limited to:
o Traumatic Arrest or peri-arrest
o Massive blood loss with profound hemorrhagic/hypovolemic shock
o Unstable patients with anticipated massive blood loss
o Ongoing or uncontrollable gastrointestinal hemorrhage

 Any patient who in the Attending’s judgment will benefit from Massive transfusion
protocol

Secondary Clinical Parameters that may Indicate the Need

for Massive Transfusion
ABC Score1,2
 Penetrating Mechanism
 Systolic Blood Pressure ≤ 90 mm Hg
 Heart Rate ≥ 120 bpm
 Positive FAST abdominal views

If 2 or more of the above are present, consider activating part one of the protocol
(Score of 2 predicts 38% chance of requiring massive transfusion, 3 predicts 45%, 4 predicts 100%)

TASH Score3
 Systolic blood pressure <100 mm Hg
 Heart rate >120
 Hemoglobin <7 g/dL
 Positive FAST Exam with hemodynamic instability
 Complex long bone and/or pelvic fracture
 Base excess < - 10 mmol/L
 INR > 1.5 during resuscitation period

The more of these parameters that are present, the higher the likelihood that the
patient will require massive transfusion.

1
Nunez et al. Early Prediction of Massive Transfusion in Trauma: Simple as ABC (Assessment of Blood
Consumption) J Trauma 2009;66:346-352
2
J Trauma 2010;69(1 Supp):S33
3
Yucel et al. Trauma Associated Severe Hemorrhage (TASH)-Score. J Trauma 2006;60:1228-1236.

Revision 10/3/2010 Page 3 of 4

Obstetric Indications
 Bleeding Placental Abruption
 Bleeding Placenta Previa
 Uterine Rupture
 Placenta Accreta
 Clinical Suspicion of DIC or Consumptive Coagulopathy
 Estimated Blood Loss > 1500 ml
 Any patient in the opinion of the obstetric physician or the obstetric
anesthesiologist who may require a transfusion of > 4 units of RBCs

Revision 10/3/2010 Page 4 of 4