Massive Hemorrhage Protocol: Change a Word, Shift a Paradigm

Traumatic hemorrhage is more than a transfusion problem; it is a time-critical systems problem spanning activation, hemostatic resuscitation, monitoring, and stopping rules. Massive hemorrhage protocol reframes trauma resuscitation around coordinated team action, early coagulopathy control, and explicit triggers for escalation.

Massive Hemorrhage Protocol in Trauma

• Paradigm shift in trauma: Massive hemorrhage protocol moves beyond the classic ≥10-unit massive transfusion definition and treats exsanguinating trauma as a multidisciplinary resuscitation problem, not just a blood delivery task.
• Standardized activation triggers: Early activation works best when the trigger is preset rather than ad hoc, using tools like the ABC score, shock index, or a critical administration threshold. We walk through how to build that trigger in the episode.
• Balanced component therapy: Blood products should be delivered in a balanced institutional ratio, and centers without FFP can substitute adjuncts such as prothrombin complex concentrate plus fibrinogen concentrate.
• TXA simplification strategy: Tranexamic acid has shifted from the old split-dose CRASH-2 approach toward a single 2 g IV strategy, with timing in the first hours of care mattering more than elegant choreography.
• Hourly coagulation reassessment: Repeat labs every hour with emphasis on coagulation studies and fibrinogen, because trauma kills through both injury-driven and resuscitation-induced coagulopathy more than a hemoglobin number alone.
• Seven T operational framework: The 7 T's give MHP a usable structure: triggers, team preparation, tranexamic acid, testing, transfusing to target, temperature management, and termination. The operational sequencing is worth hearing in the chapter.

References:

1. Petrosoniak A, Li W, Hicks C. Just the facts: massive hemorrhage protocol. CJEM. 2023;25(2):115-117.  PMID: 36469240