Trauma Transfusion Protocol

TraumaMTP
≈ 154.3 lb
Trauma transfusion packs activated
0
Adult — 6 RBC : 6 FFP : 1 platelet
Per pack — give in 1:1:1 ratio
pRBC
6 units
≈ 1.8 L
FFP
6 units
thaw early
Platelets
1 apheresis
≈ 6 units pooled

Cryoprecipitate 10 units after every 2 packs (or fibrinogen < 150 mg/dL).

TXA — within 3 h of injury
1 g IV over 10 min, then 1 g over 8 h
Pediatric: 15 mg/kg load (max 1 g) → 2 mg/kg/hr
Calcium replacement
1 g CaCl₂ (or 3 g Ca-gluconate) IV after every 2–4 units pRBC
Doses given: 0

Citrate from blood products binds Ca²⁺ → arrhythmia, coagulopathy. Recheck iCa.

Resuscitation targets
  • SBP 80–90 (permissive hypotension until hemorrhage controlled, no TBI)
  • SBP ≥ 110 if traumatic brain injury
  • Temp ≥ 36 °C — warm fluids, Bair Hugger
  • pH ≥ 7.2, iCa ≥ 1.1 mmol/L, K⁺ < 5
  • Fibrinogen > 150 mg/dL, Plt > 50 (> 100 if TBI)
On anticoagulant?
  • Warfarin → 4-factor () + 10 mg IV
  • DOAC (Xa) → or 50 units/kg
  • Dabigatran → 5 g IV
  • Heparin → 1 mg per 100 units (max 50 mg)
Blood products — quick reference
Packed RBCs (pRBC)
≈ 300 mL / unit
Effect: ↑ Hgb ≈ 1 g/dL (Hct ≈ 3%) per unit in adult
Dose: Adult: 1–2 U at a time · Peds: 10–15 mL/kg
Transfuse over 2–4 h (faster in hemorrhage). Restrictive trigger Hgb ≤ 7 (≤ 8 with cardiac dz / active bleed).
Fresh Frozen Plasma (FFP)
≈ 250 mL / unit
Effect: ↑ coag factors ≈ 5–10% per unit
Dose: 10–15 mL/kg (adult ≈ 4 U). 1:1 with pRBC in MTP.
Thaw 20–30 min — request early. Use for bleeding + INR > 1.5, warfarin reversal when PCC unavailable, TTP plasma exchange.
Platelets
Apheresis ≈ 300 mL ≈ 6 pooled units
Effect: ↑ platelet count by 30–60 K per apheresis dose
Dose: 1 apheresis (or 6 pooled) · Peds 10 mL/kg
Threshold: <10 K prophylactic, <20 K w/ fever, <50 K active bleed/procedure, <100 K CNS bleed or neurosurgery.
Cryoprecipitate
≈ 15 mL / unit (pool of 10 ≈ 150 mL)
Effect: ↑ fibrinogen ≈ 50–70 mg/dL per pool of 10
Dose: 1 pool (10 U) per 10 kg, max 1–2 pools
Use when fibrinogen < 150 mg/dL with bleeding, in MTP, DIC, or as part of obstetric hemorrhage.
4-Factor PCC (KCentra)
Reconstituted vial
Effect: Replaces II, VII, IX, X — INR normalizes in minutes
Dose: INR 2–<4: 25 U/kg · 4–6: 35 U/kg · >6: 50 U/kg (max 5000 U)
Warfarin reversal with major bleeding. Give vitamin K 10 mg IV concurrently.
Tranexamic acid (TXA)
—
Effect: Antifibrinolytic — reduces mortality if given < 3 h
Dose: 1 g IV over 10 min, then 1 g over 8 h (peds 15 mg/kg, max 1 g)
Trauma, postpartum hemorrhage, GI bleed (HALT-IT mixed). Give earlier = more benefit.
ABO / Rh emergency release
  • pRBC universal donor: O-negative (O+ acceptable in males / post-menopausal females).
  • Plasma universal donor: AB plasma (any ABO recipient).
  • Platelets: ABO-compatible preferred; Rh-negative platelets for Rh-neg females of childbearing age.
  • Type-specific blood typically available in ~10–15 min; full crossmatch ~45 min.
  • Rh-neg females of childbearing potential exposed to Rh+ blood → RhoGAM 300 mcg IM per 15 mL Rh+ pRBC.
Transfusion reactions — recognize & act
Acute hemolytic (ABO mismatch)
Clue: Fever, flank/back pain, hypotension, hemoglobinuria within minutes
Action: STOP transfusion, IVF, maintain UOP > 100 mL/h, send DAT, recheck ID, notify blood bank
Anaphylaxis (often IgA-deficient)
Clue: Urticaria, bronchospasm, hypotension
Action: STOP, epinephrine 0.3–0.5 mg IM, fluids, antihistamines/steroids; future units must be washed
TRALI
Clue: Hypoxia + bilateral infiltrates within 6 h of transfusion, no volume overload
Action: STOP, supportive O₂/ventilation, notify blood bank to quarantine donor
TACO (volume overload)
Clue: Dyspnea, HTN, JVD, B-lines within 6 h, especially in elderly / CHF
Action: Slow or stop, sit upright, furosemide, supplemental O₂
Febrile non-hemolytic
Clue: Temp rise ≥ 1 °C, chills, no hemolysis
Action: Pause, rule out hemolysis, antipyretics; leukoreduced units for future
Mild allergic / urticarial
Clue: Hives only, no airway/BP changes
Action: Pause, diphenhydramine 25–50 mg IV, restart slowly if resolved
Complications of massive transfusion
  • Hypocalcemia — citrate chelation; replace per protocol above.
  • Hyperkalemia — older units; treat with insulin/D50, calcium, β-agonist.
  • Hypothermia — use a warmer; aim ≥ 36 °C.
  • Dilutional coagulopathy / thrombocytopenia — maintain 1:1:1, give cryo for fibrinogen.
  • Acidosis — source control + perfusion; pH < 7.2 worsens coagulopathy.

Educational aid only — verify against your institution's trauma transfusion protocol.