Shock, Sepsis & Multisystem · Topic 7 of 14

Massive Transfusion & Trauma Coagulopathy

Multisystem · trauma resuscitation

Massive Transfusion & Trauma Coagulopathy

Activate early, give plasma, platelets and red cells about 1:1:1 instead of crystalloid, add tranexamic acid, and fight the lethal triad and low calcium.

Key numbers

Activate MTP: ABC score ≥ 2ABC score ≥ 2

Balanced ratio: plasma, platelets, RBCs 1:1:11:1:1

Tranexamic acid 1 g within 3 hoursTXA ≤ 3 h from injury

Keep ionized calcium normal; give calcium chlorideiCa 1.1–1.3 mmol/L

01 · Defined byActivate MTP: ABC score ≥ 2

Activate the massive transfusion protocol for ABC score ≥ 2 (1 point each: pulse > 120, SBP < 90 mmHg, positive FAST, penetrating torso injury), persistent instability, bleeding needing surgery or embolization, or trauma-bay transfusion.

02 · DoBalanced ratio: plasma, platelets, RBCs 1:1:1

Once MTP is triggered, give universal blood products instead of crystalloid near 1:1:1 (plasma:RBC 1:1 to 1:2; one apheresis platelet unit per 6 RBC units) or low-titer group O whole blood.

03 · GiveTranexamic acid 1 g within 3 hours

Give tranexamic acid to the bleeding trauma patient as soon as possible and within 3 hours of injury: 1 g IV over 10 minutes, then 1 g infused over 8 hours.

What it is

Core idea

Lethal triad: hypothermia, acidosis, coagulopathy must knowExsanguinating patients spiral into the lethal triad — hypothermia, acidosis and coagulopathy, each worsening the others; prevent all three and switch to damage control surgery when the triad appears.

Massive transfusion: > 10 RBC units/24 hMassive transfusion = more than 10 units of red cells in 24 hours (about one blood volume); only about 3% of civilian trauma patients need it, but they use 70% of a trauma center's blood.

Each 1 °C drop cuts clotting function 10%Hypothermia impairs platelets and coagulation enzymes — about 10% loss of factor function per 1 °C drop — so warm actively toward a core temperature of 36–37 °C.

Diagnosis & monitoring

Work-up

Keep ionized calcium normal; give calcium chloride must knowCitrate in each red-cell and plasma unit binds calcium: monitor ionized calcium repeatedly during massive transfusion, keep it in the normal range (1.1–1.3 mmol/L), and correct hypocalcemia with calcium chloride.

Switch from fixed ratios to goal-directed transfusionCheck INR, aPTT, fibrinogen, platelets, hemoglobin, ionized calcium and blood gas (base deficit) at least hourly, with TEG or ROTEM if available, and move from empiric ratios to goal-directed replacement as results return.

Platelets above 50 (above 100 in TBI)During ongoing bleeding keep platelets above 50 × 10⁹/L, and above 100 × 10⁹/L with traumatic brain injury; one apheresis unit is a typical dose.

Hemoglobin target 7–9 g/dLWhen red-cell transfusion is needed in the bleeding trauma patient, target hemoglobin 7–9 g/dL (70–90 g/L).

Do right now

In this order

First moves

Activate MTP: ABC score ≥ 2ABC score ≥ 2

→

Balanced ratio: plasma, platelets, RBCs 1:1:11:1:1

→

Tranexamic acid 1 g within 3 hoursTXA ≤ 3 h from injury

→

Keep ionized calcium normal; give calcium chlorideiCa 1.1–1.3 mmol/L

Why each step

Activate MTP: ABC score ≥ 2Activate the massive transfusion protocol for ABC score ≥ 2 (1 point each: pulse > 120, SBP < 90 mmHg, positive FAST, penetrating torso injury), persistent instability, bleeding needing surgery or embolization, or trauma-bay transfusion.

Balanced ratio: plasma, platelets, RBCs 1:1:1Once MTP is triggered, give universal blood products instead of crystalloid near 1:1:1 (plasma:RBC 1:1 to 1:2; one apheresis platelet unit per 6 RBC units) or low-titer group O whole blood.

Tranexamic acid 1 g within 3 hoursGive tranexamic acid to the bleeding trauma patient as soon as possible and within 3 hours of injury: 1 g IV over 10 minutes, then 1 g infused over 8 hours.

Keep ionized calcium normal; give calcium chlorideCitrate in each red-cell and plasma unit binds calcium: monitor ionized calcium repeatedly during massive transfusion, keep it in the normal range (1.1–1.3 mmol/L), and correct hypocalcemia with calcium chloride.

Management

Orders

Warm every red-cell and plasma unitGive red cells and plasma through a rapid infuser with a blood warmer — cold blood causes hypothermia, arrhythmias and arrest; never microwave blood, and do not run platelets or cryoprecipitate through the warmer.

Fibrinogen ≤ 1.5 g/L: cryoprecipitate or concentrateGive fibrinogen concentrate or cryoprecipitate when major bleeding comes with fibrinogen ≤ 1.5 g/L (150 mg/dL) or a viscoelastic fibrinogen deficit; initial dose 3–4 g (about 15–20 single-donor cryoprecipitate units).

Reverse anticoagulants: 4F-PCC plus vitamin KReverse warfarin with 4-factor PCC plus vitamin K 5–10 mg IV, dabigatran with idarucizumab, and factor Xa inhibitors with 4F-PCC; do not give routine platelets for antiplatelet drugs.

The rules

Know these

Group O red cells; Rh-negative for childbearing potentialStart uncrossmatched group O red cells — Rh-negative for females of childbearing potential (under about 45–50), Rh-positive acceptable for everyone else — with AB or low-titer A plasma; then crossmatched blood.

Permissive hypotension until bleeding is controlledTarget SBP 80–90 mmHg (MAP 50–60) until major bleeding is stopped, keeping MAP ≥ 80 mmHg in severe TBI; add norepinephrine if restricted volume cannot hold the target.

More detail

Reference

Show 6 reference facts

Each protocol defines when to stop: deactivate the MTP once bleeding is controlled and return unused products and coolers to the blood bank promptly.

Recombinant activated factor VIIa is not first-line; consider it off-label only if bleeding and coagulopathy persist despite all other measures.

Citrate and potassium toxicity worsen with hypothermia and liver failure; blood stored over a week can raise potassium in kidney failure, and hypokalemia may follow about 24 hours after transfusion of older red cells.

Viscoelastic triggers (ACS TQIP): prolonged R or ACT → plasma; low α-angle or long K → cryoprecipitate; low MA → platelets; high fibrinolysis (LY30 > 3% on rapid TEG) → antifibrinolytic.

For isolated moderate–severe TBI (GCS ≤ 12) without extracranial bleeding, consider a single 2 g IV tranexamic acid bolus within 2 hours of injury (NICE 2023); ATLS 11 summaries cite it too.

Calcium chloride is preferred for correction: 10 mL of 10% calcium chloride gives 270 mg elemental calcium versus 90 mg in 10% calcium gluconate, and may be preferable with liver dysfunction (slower citrate metabolism).

Pearl

Give blood, not saline, in balanced packs — and keep the patient warm and the ionized calcium normal while the bleeding is stopped.

Sources · ACS TQIP — Massive Transfusion in Trauma Guidelines (American College of Surgeons, 2014) · Rossaint R et al. The European guideline on management of major bleeding and coagulopathy following trauma: sixth edition. Crit Care 2023;27:80 · JournalFeed — New ATLS update: what you need to know (summary of Advanced trauma life support 2025: a brief review of updates, Injury 2026) · Merck Manual Professional — Complications of Transfusion (massive transfusion) · TCTMD — Andexanet alfa pulled from the US market (Dec 2025) · NICE NG232 Head injury: assessment and early management (2023) — recommendation 1.3.17, tranexamic acid · Starter sheet built from the verified AGACNP fact map (facts reviewed 2026-10-15).