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How to activate the Major Haemorrhage Protocol response

Call 2222 and ask the operator to activate the MHP protocol and give the location of incident. Page BTS (Page 5081) confirm products required and location needed

General response to the bleeding patient

• Initiate resuscitation: (ABC), including wide bore venous access,
• Control bleeding: (May include informing endoscopy or theatres for patient transfer),
• Send bloods urgently to appropriate laboratory
• Administer blood and blood products as soon as they are available
• Try to avoid hypothermia: warm fluids using a blood warmer

Immediate blood tests

• Crossmatch (if no valid existing group and screen sample exists);
• FBC (Hb, Platelets)
• Coagulation screen (including Fibrinogen)
• Biochemistry (including Calcium)
• Blood gases (if appropriate)

Information required by Blood Bank

1. Urgency of the situation
2. Patient details:
   Conscious patient: name, DOB, gender, CHI number
   Unconscious/ unidentified patient: gender, TH number
3. Major haemorrhage location information
   Key clinical contact: Name, Phone number/Bleep number.
   Number and nature of components required in the first instance
   Use of O negative blood
   Patient diagnosis, location of patient and any likely relocation
   Confirm which samples have been sent and how (air tube or porter).

Time frames for blood component availability

• O Negative blood immediately available
  • Uncross matched O Neg blood, A&E blood fridge (4u), Theatres Blood fridge (2u)
  • Further O Neg blood available from Blood Bank if required
• Group specific blood (ABO + RhD grouping) 15 to 20 minutes
• Fully cross-matched blood35 to 40 minutes*
• Fresh Frozen Plasma/Cryoprecipitate allow 20 minutes for thawing.
• Platelets immediately available.

*will be available quicker if valid pre-existing Group and Screen sample exists.

Massive Haemorrhage with a risk of coagulopathy

Before blood results available:

• Initial products: 4 RBC / 4 FFP
• Bleeding persists: 4 RBC / 4 FFP / 1 PLATELETS* / 2 pools of cryoprecipitate

*In active bleeding usually transfusion of platelets are unnecessary until platelet count ≤ 50 x 10⁹/L
*1 adult dose of platelets increases platelet count approx. 30-40 x 10⁹/L

Once results available, then give blood products to maintain:

• Hb > 80g/L
• PT, APTT normal limits: transfuse 4 units of FFP if APTT or PT ratio > 1.5 x normal
• Fibrinogen > 1.0g/L: transfuse 2 units of pooled cryoprecipitate if < 1.0
• Platelets ≥ 50 x10⁹/L: transfuse 1 unit of platelets (2 units if < 30 x 10⁹/L)

Massive haemorrhage, with no immediate risk of coagulopathy

Initial products: 4 RBC

If bleeding persists and still no blood results: order 4 RBC / 4 FFP / 1 unit platelets / 2 pools of cryoprecipitate (if evidence of hypofibrinogenaemia)

Once results available:, then give blood products to maintain:

• Hb > 80g/L
• PT, APTT ≤ 1.5 x normal
• Fibrinogen > 1.0g/L
• Platelets ≥ 50 x10⁹/L

*(Paediatric patients aim for platelets > 75 x 10⁹/L and Fibrinogen ≥ 1.5g/L)

Management of adverse complications following transfusion

The following complications should be anticipated and managed appropriately in patients receiving multiple units of blood components:

• Hypothermia: warm blood and blood products, monitor temperature, keep patient warm
• Hyperkalaemia: 10% CaCl₂, glucose + insulin, ß²agonist (salbutamol), bicarbonate
• Acidosis: avoid hypothermia, ensure adequate intravascular volume, check renal function
• Hypocalcaemia: give 10mL of 10% calcium chloride (for adults) by slow IV injection

* Ionised calcium results are generally available from blood gas analysis; keep Ca²⁺ > 1.0mmol/L

Tranexamic acid

The CRASH-2 trial in 2010 demonstrated that early administration of Tranexamic acid improved the survival of patients with traumatic major haemorrhage. Evidence is now emerging of benefit for other causes of major haemorrhage. The exception being acute haemorrhage secondary to a gastro-intestinal cause (The HALT-IT Trial Collaborators, Lancet 2020; 395: 1927–36).

• Initial dose given within 3 hours of trauma 1g IV over 10 minutes
• Followed by infusion of 1g over 8 hours

Recombinant activated Factor VII (Novo 7)

F VII is still occasionally used off-label as a final treatment in major haemorrhage. However systematic reviews have shown that there is no evidence of benefit and the risk of thrombo-embolic complications are substantial. If F VII is being considered in an exsanguinating patient contact the Duty Haematologist for advice.

Other pharmacological interventions using factor concentrates, anti-fibrinolytics and fibrin sealants should be considered where appropriate

Specific treatments for patients that are on oral anticoagulation

Warfarin (Vitamin K antagonist, affects Factor II, VII, IX, X)

• Treatment: Vitamin K 2.5 to 10mg IV
• Reversal with Prothrombin Complex Concentrate (Beriplex) depending on INR
  Stored Emergency Department fridge
  Ongoing advice contact the duty Haematologist

It is recommended the maximum single dose does not exceed 5000 units
Vitamin K and Beriplex should be administered through different syringes

Rivaroxaban or Apixaban (Inhibits Factor Xa)

• Reversal with Andexanet alfa (Ondexxya)
  Stored Intensive Care Unit fridge
  To use contact on-call Haematologist

Dabigatran (Inhibits Factor IIa)

• Reversal with Idarucizumab (Praxbind)
  Stored Emergency Department fridge
  To use contact on-call Haematologist

Edoxaban (Inhibits Factor Xa)

• No licensed specific antagonist yet
  Contact Haematologist

*For more information consult;

1. Management of major haemorrhage and emergency invasive procedures in patients on direct oral anticoagulants (DOACs); Jane Wylie
2. Emergency Department Anticoagulation Reversal Policy; M Rennie, J Craig

Basic Interventions

• Direct Pressure on the bleeding point
• Tourniquet if catastrophic limb haemorrhage, especially with traumatic amputations

Cell Salvage

In theatre it may be possible to reclaim blood from a surgical field. Surgery where cell salvage could be used would include vascular, trauma, orthopaedic and obstetric surgery. Reclaimed blood is filtered and washed to produce autologous blood for transfusion back into the patient.

Roughly 250 mL of salvaged blood equals 1 unit of packed red blood cells.

It is essential that Blood Bank is informed whenever the clinical emergency has ended, to minimise wastage of blood components. This is the responsibility of the Senior Clinician

Activation of the major haemorrhage response should be audited by the Hospital Transfusion Committee so that defects in the process can be identified, rectified, and lessons learned fed back to all staff involved in the major haemorrhage response.

1. The Association of Anaesthetists – Blood Transfusion and the Anaesthetist – Management of massive haemorrhage (this is a draft document, currently out for consultation)
2. Management of bleeding following major trauma: an updated European guideline, Rossaint R. et al Critical Care 2010, 14: R52
3. A practical guideline for the haematological management of major haemorrhage; Beverley J Hunt et al; British Journal of haematology (Sept 2015), Vol170 Issue 6, Pg788 – 803.
4. https://www.transfusionguidelines.org/transfusion-handbook/7-effective-transfusion-in-surgery-and-critical-care/7-3-transfusion-management-of-major-haemorrhage
5. http://www.transfusionguidelines.org/red-book