Crisis Card

Massive Transfusion

Balanced 1:1:1 resuscitation, TXA within 3 h, calcium for citrate, warm the patient.

Activate Massive Transfusion Protocol (MTP) early — don't wait for labs

Recognize

EBL > 1 blood volume OR > 4 units RBC in 1 h with ongoing need
Persistent hypotension despite resuscitation
Falling Hgb, INR ↑, fibrinogen ↓, platelets ↓
Hypothermia, acidosis, hypocalcemia (the 'diamond of death')

Doses

TXA load

1 g IV over 10 min

Within 3 h of injury

TXA infusion

1 g IV over 8 h

Calcium chloride

1 g per 4 units RBC

Central line preferred

Cryoprecipitate

10 units adult

Targets fibrinogen > 150

1:1:1 cooler

6 RBC : 6 FFP : 1 apheresis plt

Sequenced Actions

1
Activate MTP
- Call blood bank — say "Massive Transfusion Protocol"
- Will start sending coolers with 1:1:1 ratio (6 RBC : 6 FFP : 1 platelet apheresis)
- Designate one person to track products received and given
2
1:1:1 ratio (RBC : FFP : Platelets)
- Per PROPPR trial — improves hemostasis in trauma
- Once labs available, transition to goal-directed (TEG/ROTEM, fibrinogen)
- Don't wait for labs to start FFP or platelets
3
Tranexamic Acid (TXA)
- 1 g IV over 10 min (within 3 h of injury)
- Then 1 g IV over 8 h infusion
- Most effective if given EARLY — diminishing benefit after 3 h, possibly harmful after 6 h
4
Cryoprecipitate
- 10 units in an adult to keep fibrinogen > 150 mg/dL (200 in OB)
- 1 unit cryo ≈ 5× fibrinogen of 1 unit FFP
- Consider fibrinogen concentrate (RiaSTAP) if available
5
Calcium
- 1 g CaCl₂ (or 3 g Ca gluconate) per 4 units RBC
- Citrate binds Ca²⁺ → ↓ ionized Ca → hypotension, prolonged QT
- Check ionized Ca q30 min; goal > 1.1 mmol/L
6
Permissive hypotension
- Target SBP 80–90 mmHg until source control in non-TBI patients
- ≥ MAP 65 in TBI to maintain CPP
- Avoid dilutional coagulopathy from crystalloid overload
7
Warm the patient
- Fluid warmer (Belmont, Level 1)
- Forced-air warming, blankets, ↑ room temperature
- Hypothermia worsens coagulopathy dramatically below 35 °C
8
Targets
- Hgb > 7 (8 if cardiac disease)
- Platelets > 50,000 (100,000 if intracranial/ocular)
- Fibrinogen > 150–200 mg/dL
- INR < 1.5
- iCa > 1.1 mmol/L
- Temperature > 36 °C
- pH > 7.2

Common Pitfalls

Giving 'balanced crystalloid' as the primary resuscitation fluid — dilutes coagulation factors.
Forgetting calcium replacement — citrate toxicity is common at high transfusion rates.
Delaying TXA beyond 3 hours.
Not warming aggressively — hypothermia + acidosis + coagulopathy = lethal triad.

References & Further Reading

1
GuidelineOpen source
Practice Guidelines for Perioperative Blood Management: An Updated Report by the American Society of Anesthesiologists Task Force. Anesthesiology. 2015;122(2):241-275.
2
Journal
Holcomb JB, Tilley BC, Baraniuk S, et al. Transfusion of Plasma, Platelets, and Red Blood Cells in a 1:1:1 vs a 1:1:2 Ratio and Mortality in Patients With Severe Trauma: PROPPR Randomized Clinical Trial. JAMA. 2015;313(5):471-482.
3
Journal
Vlaar APJ, Toy P, Fung M, et al. A consensus redefinition of transfusion-related acute lung injury. Transfusion. 2019;59(7):2465-2476.
4
Textbook
Gropper MA, Miller RD, Cohen NH, et al., eds. Miller's Anesthesia. 9th ed. Philadelphia: Elsevier; 2020.

Citations are provided to direct further study. Always check the most current edition of guidelines and society recommendations — the information in this chapter is a teaching summary, not primary source material.

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