Massive Transfusion Protocol

Quick Answer

Massive Transfusion Protocol (MTP) is a pre-established protocol for rapid delivery of blood products to exsanguinating patients. Trigger activation when any one of: predicted blood loss greater than 100% blood volume, ongoing haemorrhage with SBP less than 90 despite 1L crystalloid, or ABC score greater than or equal to 2. Use 1:1:1 ratio (PRBC:FFP:Platelets) based on PROPPR trial. Administer TXA 1g IV loading within 3 hours. Give calcium gluconate 1g after every 4 units PRBC. Monitor for hypothermia, acidosis, hypocalcaemia, and citrate toxicity.

ACEM Exam Focus

Written Exam: ABC score components and cut-offs, 1:1:1 vs 1:1:2 ratio evidence, TXA timing and dosing, blood product composition and thawing times, massive transfusion definitions, fibrinogen and calcium targets.

Viva: MTP activation criteria, component therapy logistics, viscoelastic testing interpretation, management of refractory coagulopathy, massive transfusion complications, communication with blood bank, trauma team leadership in massive haemorrhage.

OSCE: Leading a massive transfusion, interpreting coagulation results during active haemorrhage, managing MTP activation decision, communicating with relatives during ongoing resuscitation, adjusting ratios based on viscoelastic testing.

Key Points

• Massive transfusion definition: Greater than 10 units PRBC in 24 hours, greater than 4 units in 1 hour, or greater than 50% blood volume replacement in 3 hours

• ABC score: Penetrating mechanism, SBP less than 90 mmHg, HR greater than 120 bpm, FAST positive. Score greater than or equal to 2 has 86% PPV for MTP requirement

• PROPPR trial: 1:1:1 ratio reduced early mortality (24-hour) by 4.6% absolute, 30-day mortality similar, less death from exsanguination

• TXA timing: CRASH-2 trial showed mortality benefit only when given within 3 hours (1.5% vs 5.4% increase in mortality after 3 hours)

• Calcium replacement: Hypocalcaemia occurs due to citrate in stored blood; give calcium gluconate 1g after every 4 units PRBC to maintain ionised calcium above 1.0 mmol/L

• Viscoelastic testing: ROTEM/TEG reduces blood product use, improves outcomes. Target FIBTEM A10 greater than or equal to 7-8 mm for fibrinogen supplementation

• Massive transfusion pack: Pre-assembled blood products for rapid release. Standard Australian pack: 6 units PRBC, 4 units FFP, 1 adult dose platelets (or 1 therapeutic dose cryoprecipitate)

• Whole blood: Low-titre O-positive whole blood becoming available in Australian centres. Reduces total blood product exposure, improves outcomes in military studies

• Termination criteria: No ongoing bleeding for 2 hours, SBP greater than 90 and stable, pH greater than 7.25, lactate less than 4, temperature greater than 35 degrees C, coagulation parameters stable

• Indigenous health: Aboriginal and Torres Strait Islander patients have higher rates of massive haemorrhage from trauma; ensure cultural safety in communication, involve family and elders in decision-making when appropriate

• Remote/rural: Activate early inter-facility transfer to major trauma centre; RFDS and retrieval services can transport blood products; consider pre-hospital TXA administration by aeromedical retrieval

Clinical Overview

Epidemiology

Massive transfusion occurs in approximately 10-25% of major trauma patients requiring blood products. Mortality ranges from 30-50%, highest in patients with uncontrolled haemorrhage at 24 hours. The leading cause of preventable death in trauma is haemorrhage (30-40%), with massive transfusion protocols aiming to address acute coagulopathy of trauma.

Australian epidemiology (Aus-ROC Epistry data):

• Major trauma incidence: 21-24 per 100,000 population annually
• Massive haemorrhage requiring MTP: 1-2 per 100,000
• Higher incidence in rural/regional areas (1.8× urban) due to transport delays and mechanism of injury
• Aboriginal and Torres Strait Islander Australians: 1.9× higher rate of massive haemorrhage from trauma

Risk factors for massive transfusion:

• Penetrating trauma (higher incidence than blunt)
• SBP less than 90 mmHg on arrival
• Base deficit greater than or equal to minus 6
• FAST positive for haemoperitoneum
• Pelvic fracture with active bleeding
• Coagulopathy on admission (INR greater than 1.5, aPTT greater than 50)
• Elevated lactate (greater than 5 mmol/L)

Pathophysiology

Acute Coagulopathy of Trauma (ACoT)

Trauma-induced coagulopathy occurs independently of fluid administration or hypothermia, driven by:

1. Protein C activation: Tissue injury and shock cause endothelial activation and thrombomodulin release, activating protein C which inactivates factor Va and VIIIa

2. Endothelial glycocalyx degradation: Shedding of glycocalyx releases heparan sulfate, contributing to anticoagulation

3. Fibrinogen depletion: Fibrinogen is first clotting factor to become critically low, dropping below 1.0 g/L with blood loss greater than 150% blood volume

4. Platelet dysfunction: Platelet count and function decline after 6 units PRBC, worsened by dilution and hypothermia

5. Hyperfibrinolysis: Trauma causes early fibrinolysis (minutes to hours), preceding late fibrinolysis shutdown

Time course:

• 0-30 minutes: Tissue injury and hypoperfusion trigger protein C activation
• 30-60 minutes: Dilutional coagulopathy begins with crystalloid administration
• 1-3 hours: Hypothermia worsens platelet dysfunction and enzymatic clotting
• Greater than 3 hours: Hyperfibrinolysis shutdown may contribute to thrombosis

Lethal Triad

The Lethal Triad describes interplay of three factors that worsen coagulopathy:

Lethal Diamond

Modern trauma resuscitation recognises hypocalcaemia as fourth component of coagulopathy, termed "Lethal Diamond":

• Ionised calcium target: Greater than or equal to 1.0-1.1 mmol/L
• Citrate toxicity: Each unit of stored blood contains 3g citrate, chelating calcium
• Impact: Hypocalcaemia impairs cardiac contractility, worsens hypotension, and reduces clotting factor activity
• Calcium after 4 units: Ionised calcium drops below 1.0 mmol/L after 4-6 units PRBC in most patients

Hypocalcaemia mortality association: Ionised calcium less than 1.0 mmol/L on admission is associated with 2.3-fold increased mortality in trauma patients requiring massive transfusion.

Blood Product Physiology

Packed Red Blood Cells (PRBC)

• Volume: 250-300 mL per unit (haematocrit 55-65%)
• Storage: 4°C for 35-42 days (SAG-M or AS-1 additive solution)
• 2,3-DPG depletion: Occurs after 2 weeks storage, reduces oxygen off-loading
• Storage lesions: After 14 days: reduced 2,3-DPG, increased potassium, microparticle release

Potassium considerations:

• Day 0: 4 mmol/L; Day 21: 20-30 mmol/L; Day 35: 40-60 mmol/L
• Risk: Hyperkalaemia with massive transfusion, especially in renal failure

Fresh Frozen Plasma (FFP)

• Volume: 200-250 mL per unit
• Composition: All clotting factors, fibrinogen (2-4 g/L), protein C and S, antithrombin
• Thaw time: 20-30 minutes at 37°C (2-3 minutes with rapid thawer)
• Sodium content: 170-180 mmol/L (hypernatraemia risk with massive volumes)

ABO compatibility: Requires ABO-compatible plasma. O-negative patients receive AB plasma if O-universal not available.

Platelets

• Volume: 200-300 mL per adult dose (6-unit pooled buffy coat or apheresis)
• Dose: 1 adult dose (approximately 3-4 × 10^11 platelets) increases platelet count by 30-50 × 10^9/L
• Storage: Room temperature (20-24°C) with agitation, shelf life 5-7 days
• ABO compatibility: Preferred but not essential. RhD-negative females less than 50 years require RhD-negative platelets

Platelet count considerations:

• Greater than 100 × 10^9/L: Adequate for surgery/trauma
• 50-100 × 10^9/L: May be adequate for uncomplicated surgery
• Less than 50 × 10^9/L: Transfuse if ongoing bleeding

Cryoprecipitate

• Volume: 10-15 mL per unit
• Composition: Fibrinogen (200-400 mg/unit), factor VIII, von Willebrand factor, factor XIII, fibronectin
• Indication: Fibrinogen less than 1.5-2.0 g/L or FIBTEM A10 less than 7-8 mm
• Dose: 10 units (2 pools) increases fibrinogen by 1 g/L in 70 kg adult
• Thaw time: 10-15 minutes at 37°C

Whole Blood

• Low-titre O-positive (LTOWB): Contains anti-A and anti-B titres less than 50
• Volume: 450-500 mL (equivalent to 1 unit PRBC + plasma + platelets)
• Storage: 4°C for 21-35 days
• Advantages: Reduced total blood product exposure, provides platelets and plasma, better volume-to-oxygen ratio

Australian availability: LTOWB now available in major trauma centres (Melbourne, Sydney, Brisbane) under Walking Blood Bank program or from blood bank stock.

Massive Transfusion Definition

Multiple definitions exist, reflecting clinical spectrum:

Blood volume estimation:

• Adults: 70 mL/kg; Children: 80 mL/kg; Infants: 85-90 mL/kg

Clinical thresholds for activation:

• Anticipated blood loss greater than 100% blood volume
• Ongoing haemorrhage with SBP less than 90 mmHg despite 1 L crystalloid
• ABC score greater than or equal to 2
• FAST positive with hypotension (SBP less than 90)
• Base deficit greater than or equal to minus 6 with active bleeding

Clinical Approach

Initial Assessment and MTP Activation

Decision Algorithm

Massive Haemorrhage Suspected?
│
├─ Penetrating mechanism (stab, GSW, blast)
├─ SBP less than 90 mmHg on arrival
├─ FAST positive for haemoperitoneum or haemothorax
├─ Pelvic fracture with hypotension
├─ Base deficit greater than or equal to minus 6
└─ Active external haemorrhage requiring tourniquet
     │
     └─ YES → Calculate ABC Score
            │
            └─ ABC score greater than or equal to 2?
                 ├─ YES → Activate MTP immediately
                 │         Request Massive Transfusion Pack (Pack 1)
                 │         Order 1:1:1 ratio (PRBC:FFP:Platelets)
                 │         Give TXA 1g IV loading dose (within 3 hours)
                 │         Warm all fluids to 37-39°C
                 │         Insert large-bore IV access (14G or 16G)
                 │         Insert arterial line and rapid infuser
                 │         Order viscoelastic testing (ROTEM/TEG)
                 │         Notify blood bank (direct activation line)
                 │
                 └─ NO → Clinical judgement
                    Consider MTP activation if:
                    - High-risk mechanism
                    - Deteriorating haemodynamics
                    - Diffuse bleeding on FAST
                    - Coagulopathy present

ABC Score (Assessment of Blood Consumption)

Cut-offs:

• Score 0: 4% probability of massive transfusion
• Score 1: 13% probability
• Score greater than or equal to 2: 86% probability (PPV)
• Score greater than or equal to 3: 96% probability

Performance: Sensitivity 75% for MTP requirement, specificity 86%, NPV 87% (score less than 2), PPV 86% (score greater than or equal to 2).

Australian validation: Validated in Australian trauma populations (Melbourne, Sydney), maintained similar performance. Particularly useful in high-volume penetrating trauma centres.

Additional Predictors

For high-risk patients with ABC score less than 2, consider:

1. Lactate: Greater than 4-5 mmol/L predicts massive transfusion with LR 3.2
2. Base deficit: Greater than or equal to minus 6 has sensitivity 89% for massive transfusion
3. Viscoelastic testing: FIBTEM A10 less than 7 mm on arrival predicts massive transfusion (sensitivity 85%)
4. Hemoperitoneum on CT: Grade 3-4 splenic or liver injury predicts massive transfusion
5. Pelvic fracture with displacement: 40-60% require massive transfusion
6. Combined penetrating mechanism + shock: Greater than 90% require MTP

MTP Activation Protocols (Australia):

Blood Bank Communication

Essential information to provide:

1. Patient identifier: Name, DOB, MRN (or unknown male/female age)
2. MTP status: "Activate Massive Transfusion Protocol for [name], pack 1"
3. Clinical context: Mechanism (penetrating/blunt), injuries (if known), SBP, HR
4. ABO/RhD status: If known; if unknown, specify "emergency release" status
5. Special requirements: CMV-negative (for transplant patients), irradiated (for immunocompromised), washed (for IgA deficiency)
6. Estimated duration: "Ongoing massive haemorrhage, anticipate multiple packs"
7. Contact person: "Contacting from [phone] when pack 1 received, will request pack 2"

Emergency release provisions:

• Life-threatening emergency: Release uncrossmatched O-negative PRBC immediately
• Male or post-menopausal female: O-positive acceptable
• Document in medical record and patient blood management form

Blood bank activation sequence:

Pack 1: Released immediately (within 5-10 minutes)
        - 6 units O-negative PRBC
        - 4 units AB plasma (thawing)
        - 1 adult dose platelets (pool preparation)

Pack 2: Released on request (typically 10-15 minutes after pack 1)
        - Same composition as pack 1
        - Cryoprecipitate may be added (10 units)

Pack 3+: Ongoing MTP, blood bank continues release
        - May shift to type-specific blood (if crossmatch complete)
        - Adjust ratios based on laboratory and viscoelastic testing

Component Therapy Logistics

PRBC Administration

• Access: Two large-bore peripheral IVs (14G preferred, 16G acceptable) or rapid infuser with Level 1 trauma line
• Infusion rate: 1 unit per 5 minutes via rapid infuser under pressure (300 mmHg)
• Warming: All PRBCs warmed to 37-39°C using fluid warmer (avoid in-line blood warmer without warming capacity)
• Pressure: Use commercial rapid infuser (Level 1, Belmont) or manual pressure bag (300 mmHg maximum)
• Compatibility: O-negative (universal donor), O-positive (universal for males and post-menopausal females), Type-specific (switch once crossmatch complete)

FFP Administration

• Thawing: 20-30 minutes at 37°C (2-3 minutes with rapid thawer)
• Compatibility: ABO-compatible plasma preferred; AB plasma universal for FFP
• Dose: 15-20 mL/kg (approximately 4 units for 70 kg adult)
• Sodium load: Each unit contains 170-180 mmol/L sodium; monitor for hypernatraemia

ABO plasma compatibility:

Practical administration:

• Keep FFP at room temperature once thawed (use within 24 hours)
• Administer through blood administration set with 170-200 μm filter
• Infuse rapidly to maintain 1:1 ratio
• Do not warm FFP in microwave; use fluid warmer (37-39°C)

Platelet Administration

• Preparation: 10-15 minutes to pool and issue (apheresis platelets ready immediately)
• ABO compatibility: Preferred but not mandatory
• RhD compatibility: RhD-negative females less than 50 years must receive RhD-negative platelets (or give anti-D prophylaxis)

Dose: Adult 1 adult dose (6-unit pool or apheresis); Children 10-15 mL/kg (one unit); Frequency every 1-2 hours during massive transfusion (every pack)

Administration:

• Store at room temperature (20-24°C) with gentle agitation
• Infuse through platelet administration set (170-200 μm filter, different from PRBC/FFP set)
• Do NOT warm platelets (room temperature)
• Infuse over 20-30 minutes (rapid infusion can cause severe reactions)

Platelet count monitoring:

• Baseline (pre-transfusion), after each pack (every 4-6 units PRBC)
• Target: Greater than 50 × 10^9/L with ongoing bleeding, greater than 100 × 10^9/L if surgical intervention planned

Cryoprecipitate Administration

• Indication: Fibrinogen less than 1.5-2.0 g/L or FIBTEM A10 less than 7-8 mm
• Dose: 10 units (2 pools) for 70 kg adult (increases fibrinogen by approximately 1 g/L)
• Thawing: 10-15 minutes at 37°C
• Compatibility: Universal (no ABO matching required)

Administration:

• Pool 5 single units into 1 pool (use 2 pools = 10 units total)
• Administer through blood administration set
• Infuse rapidly (over 10-15 minutes)
• May be added to MTP packs after pack 2 if fibrinogen low

Fibrinogen targets: Target greater than 2.0 g/L (or greater than 1.5 g/L if limited supply); Recheck after cryoprecipitate administration; FIBTEM A10 greater than or equal to 7-8 mm correlates with fibrinogen greater than 2.0 g/L

Viscoelastic Testing Guidance

ROTEM (Rotational Thromboelastometry)

ROTEM parameters:

Clinical interpretation:

1. Prolonged EXTEM CT + normal FIBTEM: Factor deficiency (II, V, X) → Give FFP
2. Prolonged EXTEM CT + low FIBTEM: Combined factor and fibrinogen deficiency → Give FFP + cryoprecipitate
3. Low FIBTEM A10/MCF: Isolated fibrinogen deficiency → Give cryoprecipitate or fibrinogen concentrate
4. Prolonged INTEM CT: Contact activation deficiency → Rare, consider specific factor replacement
5. APTEM improves MCF vs EXTEM: Hyperfibrinolysis → Consider TXA if not already given

Time to result: Approximately 10-15 minutes from sample to final result.

TEG (Thromboelastography)

TEG parameters:

Clinical interpretation:

1. Prolonged R time: Factor deficiency → Give FFP
2. Low α-angle: Fibrinogen deficiency or platelet dysfunction → Give cryoprecipitate or platelets
3. Low MA: Fibrinogen or platelet deficiency → Distinguish by TEG-PM (platelet mapping)
4. Elevated LY30: Hyperfibrinolysis → TXA (within 3 hours)

Protocol-Based vs Viscoelastic Testing

Protocol-based (1:1:1 ratio):

• Advantages: Simple, no need for ROTEM/TEG, rapid initiation
• Disadvantages: May over-transfuse, higher costs, transfusion-associated complications
• Indication: All massive haemorrhage initially, centres without viscoelastic testing

Viscoelastic-guided:

• Advantages: Targeted therapy, reduces blood product use (15-30% reduction), improved outcomes
• Disadvantages: Requires equipment and training, 10-15 minute delay for results
• Indication: Centres with ROTEM/TEG availability, after initial pack 1 or 2

Hybrid approach (most Australian major trauma centres):

• Start 1:1:1 ratio with MTP activation
• Obtain ROTEM/TEG on arrival
• Adjust ratios after pack 1 or 2 based on viscoelastic results
• Goal: Reduce unnecessary blood product administration while ensuring adequacy

Investigations

Immediate Bedside Testing

Point-of-Care (POC) Coagulation

• INR/aPTT: Handheld devices (i-STAT, CoaguChek) within 2-3 minutes
• INR target: Less than 1.5 (ideally 1.0-1.2) during massive transfusion
• Limitations: Does not detect fibrinogen deficiency or platelet dysfunction

Haemoglobin (POC)

• Method: Spun haematocrit or POC analyser (i-STAT)
• Hb target: Greater than 70-80 g/L (greater than 90-100 g/L if TBI or cardiovascular disease)
• Interpretation: Hb is diluted during massive transfusion; may underestimate ongoing blood loss

Fibrinogen (Clauss method, POC)

• Target: Greater than 2.0 g/L during active haemorrhage
• Time: 5-10 minutes with POC analyser
• Advantages: More sensitive than standard fibrinogen assays

Ionised Calcium

• Target: Greater than or equal to 1.0-1.1 mmol/L
• Frequency: After every 2 units PRBC
• Intervention: Calcium gluconate 1g IV if less than 1.0 mmol/L

Laboratory Testing

Complete Blood Count (CBC)

• Components: Hb, Hct, platelet count, WBC
• Platelet count target: Greater than 50 × 10^9/L with ongoing bleeding, greater than 100 × 10^9/L if surgery required
• Frequency: Baseline, after pack 1, then every 2-4 units PRBC

Coagulation Profile

• Components: INR, aPTT, fibrinogen (Clauss), D-dimer
• INR target: Less than 1.5 during active haemorrhage
• Fibrinogen target: Greater than 2.0 g/L
• Frequency: Baseline, after pack 1, then every 4-6 units PRBC

Fibrinogen

• Method: Clauss assay (more accurate than derived fibrinogen)
• Time: 15-20 minutes to result
• Critical value: Less than 1.5 g/L → Strong indication for cryoprecipitate or fibrinogen concentrate

Thromboelastography/ROTEM

• Components: CT, A10, MCF (ROTEM); R, K, α-angle, MA, LY30 (TEG)
• Frequency: On arrival (baseline), after pack 1, then as clinically indicated
• Guidance: Directs fibrinogen, FFP, platelet, and antifibrinolytic therapy

Blood Gas (ABG/VBG)

• Components: pH, PaCO2, PaO2, base deficit, lactate, electrolytes, ionised calcium
• pH target: Greater than 7.25 (ideally greater than 7.35)
• Base deficit: Greater than or equal to minus 6 predicts massive transfusion
• Lactate: Trend over time; clearance predicts survival
• Frequency: On arrival, after pack 1, then every 2-4 units PRBC or every 30 minutes

Crossmatch

• Type and screen: 15-20 minutes
• Type and cross: 45-60 minutes
• Emergency release: Uncrossmatched O-negative immediately (MTP activation)

Trauma Imaging

FAST (Focused Assessment with Sonography in Trauma)

• Components: Right upper quadrant (Morrison's pouch), left upper quadrant (splenorenal), pelvis, pericardium
• Positive: Hypotensive patient with free fluid → Immediate OR, activate MTP if not already
• Time: 2-3 minutes

CT Angiography

• Indication: Haemodynamically stable patients with suspicion of active bleeding
• Findings: Extravasation of contrast, arterial injury, solid organ injury grade
• Time: 10-15 minutes (including transfer and positioning)
• Contrast: Use iso-osmolar contrast; monitor for contrast-induced nephropathy

Portable Pelvic X-ray

• Indication: Pelvic fracture suspicion in blunt trauma
• Findings: Pelvic ring disruption, sacroiliac joint widening
• Management: Pelvic binder if fracture present, consider angio-embolisation

Management

Pre-MTP Preparation

Team Roles

MTP activation roles:

1. Team leader: Decision to activate MTP, communicate with blood bank, coordinate resuscitation
2. Airway: Secure airway, ensure adequate oxygenation
3. Circulation: Insert large-bore IVs, rapid infuser setup, administer blood products
4. Laboratory: Draw bloods, send to lab, obtain viscoelastic testing, monitor results
5. Scribe: Document times, blood product administration, vitals, team communications
6. Anaesthetics: Assist with airway, line insertion, administer medications, communicate with OR
7. Blood bank liaison: Direct communication with blood bank, track pack release
8. Nursing: Blood product administration, monitor for transfusion reactions, document

Communication during MTP: Closed-loop communication; Clear announcements: "Pack 1 received, commencing PRBC administration"; Time tracking: Record time of MTP activation, each unit administration, OR arrival; Handover: Clear to OR team if patient transferred to theatre

Equipment Preparation

Essential equipment:

• Large-bore IV access (two 14G or 16G lines) or rapid infuser
• Level 1 trauma line or Belmont rapid infuser
• Blood warming device (37-39°C capacity)
• Pressure bags (300 mmHg capacity)
• Blood administration sets (170-200 μm filter)
• Platelet administration set (separate from PRBC/FFP)
• Arterial line and invasive monitoring
• Large-bore central line or Cordis if rapid infuser not available
• Infusion pump for medications (vasopressors, calcium, TXA)
• Point-of-care testing devices (i-STAT, ROTEM/TEG)
• Infusion warmer blankets, active warming devices (Bair Hugger)
• Temperature monitoring (esophageal or rectal probe)

Blood product storage:

• PRBCs: 4°C refrigerator (blood bank)
• FFP: -30°C freezer (thawed in 37°C water bath or rapid thawer)
• Platelets: Room temperature (20-24°C) agitator
• Cryoprecipitate: -30°C freezer (thawed similar to FFP)

Massive Transfusion Protocol Execution

Phase 1: Activation (0-10 minutes)

Immediate actions:

1. Activate MTP (call blood bank directly)
2. Order TXA 1g IV loading dose (must be within 3 hours of injury)
3. Insert large-bore IV access or rapid infuser
4. Order viscoelastic testing (ROTEM/TEG)
5. Order baseline labs (CBC, coagulation, fibrinogen, ABG, ionised calcium)
6. Place arterial line and invasive monitoring
7. Begin active warming (38-39°C) for all fluids
8. Identify massive transfusion pack components

Documentation:

• Time of MTP activation
• ABC score
• SBP, HR, temperature
• INR, platelet count, fibrinogen (if available)
• Estimated blood loss
• Suspected source of haemorrhage

Communication with blood bank:

"Activate Massive Transfusion Protocol for [patient name].
Pack 1: 6 units O-negative PRBC, 4 units AB plasma, 1 adult dose platelets.
ABC score [X], SBP [X], mechanism [X].
Continuing haemorrhage, anticipate multiple packs.
Contacting from [phone number] when pack 1 arrives."

Phase 2: Resuscitation (10-60 minutes)

Blood product administration:

• Pack 1: 6 PRBC, 4 FFP, 1 platelet
  • "PRBC: 1 unit/5 minutes via rapid infuser"
  • "FFP: Thawed, infuse rapidly after PRBCs"
  • "Platelets: Infuse over 20-30 minutes (do not warm)"
• Adjuncts:
  • "TXA: 1g IV loading (if not already given), then 1g over 8 hours"
  • "Calcium gluconate: 1g IV after every 4 units PRBC (monitor ionised calcium)"
  • "Fibrinogen: If FIBTEM A10 less than 7-8 mm or fibrinogen less than 1.5 g/L, give cryoprecipitate 10 units"

Viscoelastic testing interpretation:

• ROTEM/TEG baseline: On arrival (before first blood product if possible)
• After pack 1: Recheck viscoelastic parameters
• Adjustment:
  • "Low FIBTEM A10: Add cryoprecipitate to pack 2"
  • "Prolonged EXTEM CT with normal FIBTEM: Continue FFP (1:1 ratio adequate)"
  • "Low platelet count: Ensure platelets included in each pack"
  • "Hyperfibrinolysis (LY30 greater than 7.5%): Ensure TXA given (if within 3 hours)"

Calcium management:

• Baseline: Ionised calcium
• After 4 units PRBC: Check ionised calcium
• Intervention: Calcium gluconate 1g IV if ionised calcium less than 1.0 mmol/L
• Severe hypocalcaemia (less than 0.8 mmol/L): Calcium chloride 1g IV (more potent, must give through central line)

Temperature management:

• Active warming: 38-39°C for all blood products and crystalloids
• Patient warming: Forced-air warming blanket (Bair Hugger), warmed blankets, increase ambient temperature
• Monitoring: Core temperature (esophageal or rectal probe)
• Target: Greater than 35°C (ideally 36-37°C)

Acidosis management:

• Target: pH greater than 7.25 (ideally greater than 7.35)
• Interventions: Permissive hypotension (SBP 80-90 mmHg) until bleeding controlled, Limit crystalloid use (avoid crystalloid-to-blood ratio greater than 1.5), Correct hypothermia, Restore tissue perfusion with blood products, Consider sodium bicarbonate if pH less than 7.1 and symptomatic (not routine)

Phase 3: Re-evaluation and Adjustment (60-120 minutes)

Laboratory and viscoelastic reassessment:

• After pack 2 (12 PRBC, 8 FFP, 2 platelets):
  • CBC (Hb, platelet count)
  • Coagulation (INR, aPTT, fibrinogen)
  • ROTEM/TEG
  • ABG (pH, base deficit, lactate, ionised calcium)
  • Electrolytes (potassium, sodium)

Decision points:

1. Continuing MTP:

   • Ongoing haemorrhage (confirmed by imaging, operative findings, ongoing hypotension)
   • Lactate not clearing or rising
   • Base deficit worsening
   • Haemoglobin falling despite transfusion
   • Continue MTP, request pack 3

2. Reducing MTP intensity:

   • Bleeding controlled surgically (hemostasis achieved)
   • SBP stable greater than 90 mmHg without vasopressors
   • Lactate decreasing
   • INR less than 1.5, fibrinogen greater than 2.0 g/L, platelets greater than 50 × 10^9/L
   • Continue blood products but reduce frequency (every 4-6 units PRBC rather than pack-based)

3. Terminating MTP:

   • No ongoing bleeding for 2 hours
   • SBP greater than 90 mmHg and stable
   • pH greater than 7.25
   • Lactate less than 4 mmol/L (or decreasing)
   • Temperature greater than 35°C
   • Coagulation parameters stable (INR less than 1.5, fibrinogen greater than 2.0 g/L, platelets greater than 50 × 10^9/L)
   • Transition to standard blood product administration

Adjustment based on viscoelastic testing:

Adjunctive Therapies

Tranexamic Acid (TXA)

Mechanism: Antifibrinolytic that competitively inhibits plasminogen activation and plasmin binding to fibrin.

CRASH-2 trial evidence:

• 20,211 trauma patients with significant bleeding or risk of significant bleeding
• TXA 1g IV loading over 10 minutes, then 1g infusion over 8 hours
• All-cause mortality: 14.5% vs 16.0% (RR 0.91, 95% CI 0.85-0.97)
• Absolute mortality reduction: 1.5% (NNT 67)

Timing is critical:

• Within 1 hour: 5.3% vs 7.7% mortality (RR 0.68)
• 1-3 hours: 15.6% vs 17.1% mortality (RR 0.91)
• After 3 hours: 18.1% vs 15.9% mortality (RR 1.13, potential harm)

Dosing: Loading dose 1g IV over 10 minutes (must be within 3 hours of injury); Maintenance dose 1g IV over 8 hours (optional, based on CRASH-2 protocol); For massive haemorrhage: Give loading dose immediately on arrival if within 3-hour window

Contraindications: Suspected intracranial haemorrhage (relative; CRASH-2 subgroup analysis showed no harm in isolated TBI with mild GCS impairment); Greater than 3 hours since injury; History of thromboembolic disease (relative); Active deep vein thrombosis or pulmonary embolism

Australian guidelines: ANZCOR Guideline 9.1.1: Recommend TXA for trauma patients with significant bleeding or risk of significant bleeding; Australian trauma centres: Routine administration for all trauma patients with SBP less than 90 mmHg or SBP greater than 90 mmHg but heart rate greater than 110 bpm

Calcium Replacement

Rationale: Citrate in stored blood chelates ionised calcium, causing hypocalcaemia which impairs cardiac contractility and coagulation.

Calcium gluconate vs calcium chloride:

• Calcium gluconate: 1g = 2.25 mmol calcium (less potent, can be given peripherally)
• Calcium chloride: 1g = 6.8 mmol calcium (more potent, must be given centrally)

Dosing protocol: Prophylactic Calcium gluconate 1g IV after every 4 units PRBC; Therapeutic Calcium gluconate 1g IV if ionised calcium less than 1.0 mmol/L; Severe hypocalcaemia (less than 0.8 mmol/L): Calcium chloride 1g IV central line

Target: Ionised calcium greater than or equal to 1.0-1.1 mmol/L

Monitoring: After every 2-4 units PRBC, then every 30-60 minutes

Evidence: Ionised calcium less than 1.0 mmol/L is independently associated with increased mortality (OR 2.3, 95% CI 1.4-3.7) in trauma patients receiving massive transfusion.

Fibrinogen Replacement

Indications: Fibrinogen less than 1.5-2.0 g/L; FIBTEM A10 less than 7-8 mm; Massive haemorrhage with no viscoelastic testing (empiric cryoprecipitate with pack 2 or 3)

Options:

1. Cryoprecipitate:

• Dose: 10 units (2 pools) for 70 kg adult
• Volume: 50-60 mL (per 10 units)
• Time to effect: Immediate (increase fibrinogen by approximately 1 g/L)
• Advantages: Contains factor VIII, von Willebrand factor, factor XIII
• Disadvantages: Requires thawing, viral transmission risk (theoretical)

2. Fibrinogen concentrate:

• Dose: 3-4 g for 70 kg adult (50-60 mg/kg)
• Volume: 50-100 mL (diluted in water)
• Time to effect: Immediate
• Advantages: No thawing, viral inactivation, precise dosing, lower volume
• Disadvantages: More expensive, not universally available in Australia

Australian practice: Cryoprecipitate first-line (available through blood bank). Fibrinogen concentrate (RiaSTAP) available in some centres.

Target: Fibrinogen greater than 2.0 g/L during active haemorrhage, greater than 1.5 g/L after bleeding controlled.

Recombinant Factor VIIa

Indications (off-label in trauma):

• Refractory coagulopathy despite massive transfusion (greater than 20 units PRBC)
• Life-threatening haemorrhage where surgical or radiological control impossible
• Viscoelastic testing shows functional deficiency but no clear factor deficiency

Dose: 90 μg/kg IV bolus (may repeat once after 2-3 hours if ongoing haemorrhage)

Evidence: Mixed results. Controlled trials show no mortality benefit, increased thromboembolic risk (arterial and venous). Use only as rescue therapy after conventional strategies exhausted.

Contraindications: Ongoing uncontrolled surgical bleeding; History of thromboembolic disease; Disseminated intravascular coagulation (DIC)

Prothrombin Complex Concentrate (PCC)

Indications (in massive transfusion):

• Warfarin reversal before massive transfusion (INR greater than 2.0)
• Refractory factor deficiency despite FFP administration
• Vitamin K antagonist-induced coagulopathy with life-threatening haemorrhage

Dose: 4-factor PCC (Beriplex, Octaplex): 50 IU/kg IV; Warfarin reversal: 25-50 IU/kg based on INR

Evidence: Superior to FFP for warfarin reversal (faster, more reliable, no volume load). Limited evidence in trauma-related coagulopathy without anticoagulant use.

Contraindications: History of thromboembolic disease (relative); Disseminated intravascular coagulation

Massive Transfusion Complications

Transfusion Reactions

Acute haemolytic transfusion reaction:

• Cause: ABO-incompatible blood (rare with modern blood bank practices)
• Onset: Within minutes of transfusion
• Symptoms: Fever, chills, hypotension, haemoglobinuria, oliguria
• Management: Stop transfusion immediately, support blood pressure, maintain urine output (diuretics if needed), investigate (send blood cultures, repeat crossmatch, DAT)

Febrile non-haemolytic transfusion reaction:

• Cause: Antibodies to donor leukocytes
• Onset: During or within 1-2 hours of transfusion
• Symptoms: Fever greater than 38°C, chills
• Management: Stop transfusion, antipyretics (paracetamol), continue if mild

Allergic/anaphylactic transfusion reaction:

• Cause: IgA deficiency (severe) or plasma protein antibodies
• Onset: Within minutes
• Symptoms: Urticaria, bronchospasm, hypotension, angioedema
• Management: Stop transfusion, adrenaline 0.5 mg IM for anaphylaxis, antihistamines, steroids

Transfusion-associated circulatory overload (TACO):

• Cause: Rapid volume administration
• Onset: During or within 6 hours of transfusion
• Symptoms: Dyspnoea, tachypnoea, hypertension, pulmonary oedema
• Management: Stop transfusion, diuretics, supportive oxygen, consider non-invasive ventilation

Prevention in massive transfusion: Monitor vital signs continuously; Central venous pressure or stroke volume variation monitoring; Diuretics (furosemide 20-40 mg IV) after every 6-8 units PRBC if signs of volume overload; Non-invasive ventilation early for respiratory distress

Massive Transfusion-Specific Complications

Hypothermia:

• Cause: Cold blood products, exposure in trauma bay, impaired thermoregulation
• Prevention: Warm all fluids to 37-39°C, active patient warming
• Management: Forced-air warming blankets, increase ambient temperature, consider peritoneal lavage with warm saline

Citrate toxicity (hypocalcaemia):

• Cause: Citrate in stored blood chelates ionised calcium
• Prevention: Calcium gluconate 1g after every 4 units PRBC
• Management: Calcium chloride 1g IV central line for severe hypocalcaemia (less than 0.8 mmol/L)

Hyperkalaemia:

• Cause: Potassium leak from stored PRBCs (increases with storage time)
• Risk factors: Renal failure, massive transfusion greater than 20 units, older PRBC units
• Prevention: Use freshest PRBCs available, monitor potassium after every 6-8 units
• Management: Calcium gluconate/chloride (membrane stabilisation), insulin/dextrose, consider haemodialysis for severe hyperkalaemia

Dilutional coagulopathy:

• Cause: Crystalloid dilution of clotting factors and platelets
• Prevention: Limit crystalloid use (target crystalloid:PRBC ratio less than 1.5), early FFP and platelet administration
• Management: Continue 1:1:1 ratio, viscoelastic testing-guided therapy

Acute respiratory distress syndrome (TRALI):

• Cause: Antibodies in donor plasma (less common now with plasma from male donors)
• Onset: Within 6 hours of transfusion
• Symptoms: Dyspnoea, hypoxia, bilateral infiltrates on CXR
• Management: Supportive, mechanical ventilation if needed
• Prevention: Use plasma from male donors (standard practice in Australia)

Air embolism:

• Cause: Air in blood administration set (rare with modern techniques)
• Onset: Immediate
• Symptoms: Sudden cardiovascular collapse, stroke-like symptoms
• Management: High-flow oxygen, patient positioned left lateral decubitus with head down, support

Indigenous Health Considerations

Aboriginal and Torres Strait Islander Health

Epidemiology:

• Aboriginal and Torres Strait Islander Australians have 1.9-fold higher rate of massive haemorrhage from trauma
• Higher incidence of penetrating trauma in regional communities
• Increased time to definitive care (median 120 vs 45 minutes to trauma centre)
• Higher comorbidity burden (diabetes, cardiovascular disease, renal disease)

Cultural safety:

• Communication: Use clear, plain language. Avoid medical jargon. Check understanding.
• Family involvement: Identify and involve family members and elders in decision-making (unless patient lacks capacity and family unavailable)
• Men's and women's business: Be aware of gender-specific cultural protocols. Same-gender healthcare providers preferred when possible.
• Sorry Business: Traditional mourning practices may delay care. Respect cultural obligations while ensuring patient safety.
• Language: Use Aboriginal interpreter services when language barrier exists (do not use family members as interpreters).

Barriers to care:

• Geographic remoteness (many Aboriginal communities 4-8 hours from major trauma centre)
• Transport limitations (no road access, weather-dependent aeromedical retrieval)
• Distrust of healthcare system (historical trauma, experiences of racism)
• Communication barriers (multiple Aboriginal languages, limited health literacy)

Specific considerations:

• Chronic disease: Higher prevalence of diabetes (3×), cardiovascular disease (2×), renal disease (4×) may affect resuscitation targets
• Alcohol-related trauma: Higher incidence of alcohol-related injuries; assess for withdrawal risk and social support
• Social determinants: Housing instability, poverty may affect post-discharge care and follow-up

Collaboration with Aboriginal health workers:

• Involve Aboriginal health practitioners and liaison officers in patient care
• Respect cultural protocols regarding death and dying
• Coordinate with Aboriginal Medical Services for follow-up care
• Consider cultural burial practices when discussing organ donation or autopsy

Māori Health (New Zealand Context)

Epidemiology:

• Māori have higher rates of severe trauma (1.5× non-Māori)
• Increased incidence of motor vehicle accidents and workplace injuries
• Higher rates of massive haemorrhage from interpersonal violence

Cultural considerations:

• Whānau (family) involvement: Whānau are integral to decision-making and care
• Tikanga Māori (Māori protocols): Respect for spiritual and cultural practices
• Tapu and noa: Concepts of sacredness and secular; appropriate handling of blood and body products
• Karakia (prayer): May be performed by family; allow time and space for cultural practices

Health literacy:

• Use culturally appropriate health information
• Involve Māori health providers (Kaiāwhina)
• Address health literacy barriers with visual aids and plain language

Remote and Rural Considerations

Pre-Hospital Massive Transfusion

Indications:

• Penetrating trauma with hypotension (SBP less than 90 mmHg)
• Blunt trauma with SBP less than 90 mmHg and suspected torso injury
• Pre-hospital TXA administration recommended within 3 hours

Retrieval services:

• NSW: CareFlight, NSW Ambulance Special Casualty Access Team (SCAT)
• Victoria: Ambulance Victoria Adult Retrieval Service (AVARS)
• Queensland: Queensland Ambulance Service (QAS) aeromedical retrieval
• South Australia: MedSTAR retrieval service
• Western Australia: Royal Flying Doctor Service (RFDS)

Pre-hospital blood products:

• Some retrieval services carry low-titre O-positive whole blood (LTOWB) on rotor-wing aircraft
• Others carry PRBCs (2-4 units) for remote missions
• TXA: Standard in most retrieval service protocols

Activation:

• Early activation of retrieval services for trauma patients with high-risk mechanisms
• Direct communication with receiving hospital blood bank
• Consider pre-hospital activation of MTP if transfer time greater than 60 minutes

Rural Hospital Massive Transfusion

Capacity:

• Many rural hospitals have limited blood product availability (2-4 units PRBC)
• FFP and platelets may require thawing time or retrieval from major centre
• Cryoprecipitate rarely available in rural hospitals

MTP activation in rural hospital:

1. Activate early (anticipate need before patient arrives)
2. Coordinate with regional blood bank for product release
3. Initiate TXA if within 3 hours of injury
4. Prepare for rapid transfer to major trauma centre
5. RFDS or aeromedical retrieval may bring blood products to rural hospital

Transfer considerations:

• Timing: Transfer should not be delayed for laboratory normalisation
• Stabilisation: SBP greater than 80-90 mmHg (permissive hypotension), adequate oxygenation, airway secure
• Blood products: Continue transfusion during transfer if haemorrhage ongoing
• Accompanying team: Retrieval team assumes care; clear handover with rural team

RFDS blood product transport:

• RFDS can transport blood products to rural hospitals
• Cold chain maintained throughout transport
• Priority transport for massive haemorrhage patients
• Consider "walking blood bank" if no blood products available (rare, only in extreme circumstances)

Limited Resource Management

Viscoelastic testing:

• May not be available in rural hospitals
• Rely on standard coagulation testing (INR, aPTT, fibrinogen)
• Early transfer to centre with viscoelastic testing capabilities

Whole blood use:

• LTOWB advantageous in remote settings (single product, easier logistics)
• May be carried by retrieval services
• Reduced total blood product exposure

Calcium management:

• Calcium gluconate preferred over calcium chloride (peripheral administration acceptable)
• Frequent monitoring may be limited (every 4 units PRBC pragmatically)

Temperature management:

• Limited active warming equipment in rural hospitals
• Use warmed blankets, increase ambient temperature
• Prioritise fluid warming with available equipment

Disposition

Transfer to Major Trauma Centre

Indications:

• Massive haemorrhage requiring ongoing transfusion (greater than 10 units PRBC anticipated)
• Complex injuries requiring specialised surgical intervention (angiography, damage control surgery)
• Need for intensive care with advanced monitoring
• Persistent coagulopathy despite massive transfusion

Transfer preparation:

• Blood products: Continue transfusion during transfer if haemorrhage ongoing
• Access: Secure large-bore IV access or rapid infuser
• Monitoring: Arterial line, pulse oximetry, ECG, core temperature
• Documentation: Clear handover of injuries, interventions, blood products administered, laboratory trends

Timing:

• Transfer should not be delayed for complete laboratory normalisation
• Target: Transfer initiated after initial resuscitation (after pack 1 or 2)
• SBP greater than 80-90 mmHg, adequate oxygenation, airway secured

Operative Management

Indications for immediate operative intervention:

• Penetrating torso trauma with hypotension
• Positive FAST with haemodynamic instability
• Pelvic fracture with ongoing haemorrhage (consider external fixation, angio-embolisation)
• Major vascular injury (confirmed by imaging or physical examination)

Damage control surgery:

• Philosophy: Abbreviated surgery (30-60 minutes) to control haemorrhage, ICU resuscitation, planned relook at 24-48 hours
• Techniques: Shunting, packing, rapid vascular clamping, temporary abdominal closure
• Blood products: Continue massive transfusion intraoperatively (1:1:1 ratio)
• Coagulation: Viscoelastic testing intraoperatively if available

Angiography and embolisation:

• Indications: Pelvic fracture with arterial extravasation, solid organ injury (liver, spleen, kidney) with active bleeding, arterial injury amenable to embolisation
• Timing: Within 60-90 minutes of arrival for unstable patients

Intensive Care Admission

Admission criteria:

• Ongoing massive transfusion (greater than 10 units PRBC)
• Persistent haemodynamic instability
• Multiorgan dysfunction (respiratory, renal, cardiovascular)
• Severe coagulopathy (INR greater than 1.5, fibrinogen less than 1.5 g/L)
• Need for advanced monitoring (arterial line, central line, cardiac output monitoring)

ICU management:

• Continued massive transfusion: If haemorrhage ongoing, continue 1:1:1 ratio, viscoelastic testing-guided
• Organ support: Mechanical ventilation, renal replacement therapy if needed, vasopressor support
• Monitoring: Arterial line, central line, urinary catheter, core temperature, serial labs
• Sedation and analgesia: Adjust for TBI (target sedation holidays, EVD if indicated)

Termination of Massive Transfusion

Criteria:

1. No ongoing bleeding for 2 hours
2. SBP greater than 90 mmHg and stable without vasopressors
3. pH greater than 7.25
4. Lactate less than 4 mmol/L (or decreasing trend)
5. Temperature greater than 35°C
6. Coagulation parameters stable (INR less than 1.5, fibrinogen greater than 2.0 g/L, platelets greater than 50 × 10^9/L)

Transition to standard blood product administration:

• Discontinue pre-assembled MTP packs
• Order blood products as needed based on laboratory results
• Target: Hb greater than 70-80 g/L, INR less than 1.5, fibrinogen greater than 2.0 g/L, platelets greater than 50 × 10^9/L

Documentation:

• Record termination time
• Total blood products administered (PRBC, FFP, platelets, cryoprecipitate)
• Complications (transfusion reactions, hypocalcaemia, TACO, etc.)
• Final haemodynamic and laboratory parameters

Pitfalls and Pearls

Common Mistakes

1. Delayed MTP activation: Waiting for laboratory confirmation before activating MTP. Activate based on clinical assessment and ABC score.

2. Under-transfusion of FFP and platelets: Administering PRBCs alone. Maintain 1:1:1 ratio to prevent dilutional coagulopathy.

3. Missing TXA window: Forgetting TXA or administering after 3 hours. Give 1g IV loading within 3 hours of injury.

4. Inadequate calcium replacement: Not monitoring or replacing ionised calcium. Give calcium gluconate 1g after every 4 units PRBC.

5. Hypothermia: Not warming blood products or patient. All fluids warmed to 37-39°C, active patient warming.

6. Excessive crystalloid use: Crystalloid-to-PRBC ratio greater than 1.5 worsens coagulopathy. Limit crystalloids, prioritise blood products.

7. Ignoring viscoelastic testing: Relying solely on INR for coagulation assessment. Use ROTEM/TEG to guide targeted therapy.

8. Premature MTP termination: Stopping MTP before bleeding controlled. Ensure haemostasis achieved before termination.

9. Over-reliance on haemoglobin: Focusing on Hb while ignoring ongoing bleeding and perfusion parameters. Trend lactate, base deficit, and clinical examination.

10. Missing hyperkalaemia: Not monitoring potassium with massive transfusion, especially with older PRBCs. Check potassium after every 6-8 units.

Clinical Pearls

1. ABC score greater than or equal to 2: High PPV (86%) for massive transfusion. Use for early MTP activation.

2. TXA timing matters: Mortality benefit only within 3 hours. 1-3 hour window is critical; after 3 hours, potential harm.

3. 1:1:1 ratio: Based on PROPPR trial. Reduces early mortality from exsanguination. 30-day mortality similar but improved haemostasis.

4. Calcium after 4 units: Ionised calcium drops below 1.0 mmol/L after 4-6 units PRBC in most patients. Prophylactic calcium gluconate 1g after every 4 units recommended.

5. FIBTEM A10 less than 7-8 mm: Specific for fibrinogen deficiency. Cryoprecipitate or fibrinogen concentrate indicated. Target A10 greater than 7-8 mm.

6. Viscoelastic-guided therapy: Reduces blood product use by 15-30% without increasing mortality. Consider ROTEM/TEG for all massive transfusion patients.

7. Permissive hypotension: Target SBP 80-90 mmHg until bleeding controlled, unless TBI, spinal cord injury, or pregnancy. Reduces ongoing haemorrhage and blood product use.

8. Whole blood: LTOWB may be superior to component therapy in massive haemorrhage. Reduces total blood product exposure, improves outcomes.

9. Lethal diamond: Hypothermia, acidosis, coagulopathy, hypocalcaemia. Address all four components simultaneously during resuscitation.

10. Early surgical/angiographic control: Massive transfusion is temporising. Definitive control of haemorrhage (surgery, angio-embolisation) is required for survival.

11. Massive transfusion pack: Pre-assembled for rapid release. Pack 1: 6 PRBC, 4 FFP, 1 platelet. Subsequent packs as needed.

12. Termination criteria: No ongoing bleeding for 2 hours, SBP greater than 90 and stable, pH greater than 7.25, lactate less than 4, temperature greater than 35°C, coagulation stable.

13. Remote/rural: Early activation of retrieval services. RFDS can transport blood products to rural hospitals. Consider pre-hospital LTOWB if available.

14. Indigenous health: Aboriginal and Torres Strait Islander patients have higher rates of massive haemorrhage. Ensure cultural safety, involve family and elders, consider comorbidities.

15. ABO plasma compatibility: AB plasma universal for FFP. O-negative patients may receive AB plasma if O-universal not available.

16. Platelet RhD compatibility: RhD-negative females less than 50 years must receive RhD-negative platelets or anti-D prophylaxis.

Viva Practice

Viva 1: MTP Activation and ABC Score

Stem: A 32-year-old male is brought to your trauma centre after a gunshot wound to the abdomen. On arrival, his SBP is 85 mmHg, HR 128 bpm, GCS 14. FAST shows free fluid in the abdomen. The transport team reports he lost approximately 1 L of blood at the scene.

Q1: Will you activate the Massive Transfusion Protocol? Justify your decision using the ABC score.

Model Answer: Yes, I will activate the MTP immediately.

ABC Score:

• Penetrating mechanism: Yes (gunshot wound) = 1 point
• SBP less than 90 mmHg: Yes (85 mmHg) = 1 point
• HR greater than 120 bpm: Yes (128 bpm) = 1 point
• FAST positive: Yes (free fluid in abdomen) = 1 point

Total ABC score: 4

An ABC score of 4 has a 96% positive predictive value for massive transfusion. This patient has multiple high-risk features: penetrating abdominal trauma, hypotension, tachycardia, and positive FAST. Immediate MTP activation is indicated.

Additional considerations:

• This is a classic indication for immediate operative intervention (damage control surgery)
• Anticipated blood loss greater than 100% blood volume
• I will also administer TXA 1g IV loading (assuming within 3 hours of injury)
• Request emergency release of O-negative PRBCs while awaiting MTP pack

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Q2: Describe the blood products in the first massive transfusion pack and the rationale for the 1:1:1 ratio.

Model Answer: First massive transfusion pack (Pack 1):

• 6 units PRBC (O-negative or O-positive if male/post-menopausal)
• 4 units FFP (AB plasma, thawed)
• 1 adult dose platelets (6-unit pool or apheresis)

Rationale for 1:1:1 ratio (PRBC:FFP:Platelets): The PROPPR trial (2015) compared 1:1:1 vs 1:1:2 ratios in 680 massive transfusion patients. Key findings:

• Early mortality (24 hours): 1:1:1 (12.7%) vs 1:1:2 (17.0%) – absolute reduction 4.3%, RR 0.75
• 30-day mortality: Similar between groups (26.9% vs 27.4%)
• Death from exsanguination: 1:1:1 (9.2%) vs 1:1:2 (14.6%) – significant reduction

The 1:1:1 ratio approximates whole blood composition, preventing dilutional coagulopathy. It ensures adequate plasma (factors and fibrinogen) and platelets are administered alongside PRBCs to maintain haemostatic competence.

Clinical practice:

• Start with 1:1:1 ratio for all massive transfusion activations
• Adjust after pack 1 or 2 based on viscoelastic testing (ROTEM/TEG) and laboratory results
• Goal: Reduce early death from exsanguination while minimising unnecessary blood product administration

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Q3: What adjunctive therapies will you administer alongside blood products, and why?

Model Answer: 1. Tranexamic acid (TXA):

• Dose: 1g IV loading over 10 minutes (must be within 3 hours of injury)
• Rationale: CRASH-2 trial showed mortality benefit (1.5% absolute reduction) when given within 3 hours. Antifibrinolytic effect stabilises clot formation.
• Timing critical: Mortality benefit lost after 3 hours (potential harm)

2. Calcium replacement:

• Dose: Calcium gluconate 1g IV after every 4 units PRBC
• Target: Ionised calcium greater than or equal to 1.0-1.1 mmol/L
• Rationale: Stored blood contains citrate which chelates calcium. Hypocalcaemia impairs cardiac contractility and coagulation. Ionised calcium less than 1.0 mmol/L is associated with 2.3-fold increased mortality.

3. Fibrinogen replacement (if indicated):

• Indications: Fibrinogen less than 1.5-2.0 g/L or FIBTEM A10 less than 7-8 mm
• Dose: Cryoprecipitate 10 units (2 pools) or fibrinogen concentrate 3-4 g
• Rationale: Fibrinogen is first clotting factor to become critically low. FIBTEM A10 correlates with fibrinogen level and guides targeted replacement.

4. Temperature management:

• Warm all fluids to 37-39°C
• Active patient warming (Bair Hugger, warmed blankets)
• Target: Temperature greater than 35°C (ideally 36-37°C)
• Rationale: Hypothermia reduces clotting factor activity by 10% per 1°C drop and impairs platelet function.

5. Permissive hypotension:

• Target SBP 80-90 mmHg until bleeding controlled
• Contraindications: TBI, spinal cord injury, pregnancy
• Rationale: Reduces ongoing haemorrhage, maintains tissue perfusion, limits crystalloid use.

6. Viscoelastic testing (ROTEM/TEG):

• Obtain baseline (if possible) and after pack 1
• Rationale: Guides targeted therapy, reduces total blood product use by 15-30%, improves outcomes compared to protocol-based 1:1:1 alone.

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Q4: How will you determine when to terminate the massive transfusion?

Model Answer: Termination criteria for massive transfusion:

1. No ongoing bleeding for 2 hours (confirmed by operative findings, imaging, or clinical assessment)
2. SBP greater than 90 mmHg and stable without vasopressor support
3. pH greater than 7.25 (ideally greater than 7.35)
4. Lactate less than 4 mmol/L or decreasing trend
5. Temperature greater than 35°C
6. Coagulation parameters stable:
   • INR less than 1.5
   • Fibrinogen greater than 2.0 g/L (or greater than 1.5 g/L if limited supply)
   • Platelets greater than 50 × 10^9/L (greater than 100 × 10^9/L if surgery planned)

Transition to standard blood product administration:

• Discontinue pre-assembled MTP packs
• Order blood products individually based on laboratory results
• Target: Hb greater than 70-80 g/L, INR less than 1.5, fibrinogen greater than 2.0 g/L, platelets greater than 50 × 10^9/L

Monitoring after MTP termination:

• Continue monitoring haemodynamics (SBP, HR, urine output)
• Repeat coagulation profile at 4-6 hours post-termination
• Monitor for delayed complications (TACO, citrate toxicity, hyperkalaemia)
• ICU admission if multiorgan dysfunction present

Documentation:

• Record total blood products administered (PRBC, FFP, platelets, cryoprecipitate)
• Document complications (transfusion reactions, hypocalcaemia, TACO)
• Note final haemodynamic and laboratory parameters
• Clear handover to ICU or ward team

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Viva 2: Viscoelastic Testing and Coagulopathy

Stem: You are team leader for a massive transfusion. After receiving pack 1 (6 PRBC, 4 FFP, 1 platelet), the ROTEM results are available. The patient has ongoing haemorrhage, SBP 88 mmHg, HR 125 bpm.

ROTEM results:

• FIBTEM CT: Not measurable
• FIBTEM A10: 5 mm
• FIBTEM MCF: 12 mm
• EXTEM CT: 100 seconds
• EXTEM A10: 35 mm
• EXTEM MCF: 45 mm

Q1: Interpret the ROTEM results and describe the coagulopathy.

Model Answer: ROTEM interpretation:

Coagulopathy: Combined fibrinogen deficiency and factor deficiency (likely factors II, V, X given EXTEM CT prolongation).

Pathophysiology:

• Fibrinogen deficiency: Massive haemorrhage consumes fibrinogen; first clotting factor to become critically low. FIBTEM A10 of 5 mm correlates with fibrinogen less than 1.5 g/L.
• Factor deficiency: Ongoing haemorrhage and dilution from PRBCs have depleted clotting factors. EXTEM CT prolongation (100 sec) suggests factor II, V, X deficiency.

Clinical significance:

• This coagulopathy will exacerbate ongoing haemorrhage unless corrected.
• 1:1:1 ratio alone may be insufficient. Targeted supplementation required based on ROTEM.
• Urgent intervention needed to achieve haemostasis.

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Q2: What interventions are required based on these ROTEM results?

Model Answer: Interventions:

1. Cryoprecipitate or fibrinogen concentrate:

• Indication: FIBTEM A10 6 mm (target greater than or equal to 7-8 mm)
• Dose: Cryoprecipitate 10 units (2 pools) OR fibrinogen concentrate 3-4 g
• Expected effect: Increase fibrinogen to greater than 2.0 g/L, improve FIBTEM A10 to greater than 7 mm

2. Continue FFP administration:

• Indication: Prolonged EXTEM CT (100 sec)
• Continue 1:1:1 ratio to replenish clotting factors
• Consider increasing FFP ratio if CT remains prolonged after cryoprecipitate

3. Add platelets:

• Ensure platelet dose included in pack 2 (and subsequent packs)
• Check platelet count; target greater than 50 × 10^9/L with ongoing bleeding
• Consider additional platelet dose if platelet count less than 50 × 10^9/L

4. Recheck ROTEM after intervention:

• Repeat ROTEM 15-30 min after cryoprecipitate administration
• Ensure FIBTEM A10 greater than or equal to 7-8 mm and EXTEM CT normalising (less than 100 sec)
• Adjust therapy based on repeat results

5. Continue adjunctive therapies:

• Calcium gluconate 1g after 4 units PRBC (monitor ionised calcium)
• Maintain temperature greater than 35°C
• Permissive hypotension (SBP 80-90 mmHg) until bleeding controlled

Adjunctive considerations:

• Fibrinogen concentrate: Faster, no thawing, lower volume. May be preferred if available (RiaSTAP).
• Recombinant factor VIIa: Rescue therapy only if coagulopathy refractory to above interventions (controversial, increased thrombotic risk).

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Q3: How does viscoelastic testing-guided therapy compare to protocol-based 1:1:1 therapy?

Model Answer: Protocol-based (1:1:1 ratio):

• Advantages: Simple, no need for ROTEM/TEG equipment, rapid initiation
• Disadvantages: May over-transfuse (FFP and platelets not always needed), higher costs, increased transfusion-associated complications
• Indication: All massive haemorrhage initially, centres without viscoelastic testing

Viscoelastic-guided therapy:

• Advantages:
  • Targeted therapy based on actual coagulation deficit
  • Reduces blood product use by 15-30%
  • Lower costs, fewer transfusion reactions
  • Improved outcomes in observational studies (lower mortality, less organ failure)
• Disadvantages:
  • Requires equipment and training (ROTEM or TEG)
  • 10-15 minute delay for results
  • Not universally available in rural/regional hospitals
• Evidence: Systematic review (2017) showed viscoelastic-guided therapy reduced blood product use, similar or improved mortality, and decreased complications

Hybrid approach (most Australian major trauma centres):

1. Activate MTP with 1:1:1 ratio immediately (no delay)
2. Obtain ROTEM/TEG on arrival
3. Continue 1:1:1 through pack 1
4. Adjust ratios after pack 1 or 2 based on viscoelastic results
5. Goal: Rapid initial resuscitation + targeted therapy to reduce unnecessary transfusion

Clinical decision:

• For this patient, low FIBTEM A10 indicates specific fibrinogen deficiency. Add cryoprecipitate to pack 2.
• Prolonged EXTEM CT indicates factor deficiency. Continue FFP (1:1:1 ratio).
• Recheck ROTEM after intervention to guide further therapy.

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Q4: The patient's ionised calcium is 0.85 mmol/L. How will you manage hypocalcaemia?

Model Answer: Hypocalcaemia assessment:

• Ionised calcium 0.85 mmol/L is below than target (greater than or equal to 1.0 mmol/L)
• This is moderate hypocalcaemia, likely due to citrate toxicity from PRBCs (this patient has received 6 units so far)
• Hypocalcaemia impairs cardiac contractility and coagulation, contributing to ongoing haemorrhage

Immediate intervention:

• Calcium gluconate 1g IV over 10 minutes
• Can be given peripherally (preferred over calcium chloride for moderate hypocalcaemia)
• Recheck ionised calcium in 15-30 minutes

If severe hypocalcaemia (less than 0.8 mmol/L) or refractory to calcium gluconate:

• Calcium chloride 1g IV over 10 minutes
• Must be given through central line (vesicant, can cause tissue necrosis if extravasation)
• More potent than calcium gluconate (6.8 mmol calcium vs 2.25 mmol per 1g)
• Recheck ionised calcium after 15 minutes

Prophylactic calcium replacement:

• Continue calcium gluconate 1g IV after every 4 units PRBC
• Monitor ionised calcium after every 2-4 units PRBC during massive transfusion
• Target: Greater than or equal to 1.0-1.1 mmol/L

Evidence:

• Ionised calcium less than 1.0 mmol/L is independently associated with increased mortality (OR 2.3) in trauma patients receiving massive transfusion
• Each unit of stored blood contains 3g citrate; cumulative effect leads to hypocalcaemia after 4-6 units in most patients
• Calcium replacement improves haemodynamics and coagulation in massive transfusion

Monitoring:

• Ionised calcium: After every 2-4 units PRBC, then every 30-60 minutes
• ECG: Monitor for QT prolongation, arrhythmias (signs of severe hypocalcaemia)
• Clinical: Assess for cardiac contractility, blood pressure response

Adjunctive considerations:

• Severe hypocalcaemia may contribute to vasopressor-refractory hypotension. Calcium replacement improves response to vasopressors.
• Hypocalcaemia worsens coagulopathy; correcting ionised calcium improves clot formation.

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Viva 3: Complications and Special Populations

Stem: A 45-year-old female with severe blunt trauma requires massive transfusion. She has received 12 units PRBC, 8 units FFP, and 2 platelet doses. She is now hypoxic with SpO2 88% on 15 L/min O2, bilateral crackles on auscultation, BP 145/95 mmHg, HR 110 bpm. Temperature is 34.8°C.

Q1: What is the likely diagnosis? How will you manage this complication?

Model Answer: Likely diagnosis: Transfusion-associated circulatory overload (TACO).

Key features supporting TACO:

• Massive transfusion (12 units PRBC)
• Acute respiratory distress (hypoxia, bilateral crackles)
• Hypertension (145/95 mmHg)
• Tachycardia (110 bpm)
• Temporal relationship to transfusion

Differential diagnosis:

• Transfusion-related acute lung injury (TRALI): Typically hypotensive, not hypertensive; bilateral infiltrates on CXR
• Acute respiratory distress syndrome (ARDS): Develops over 24-48 hours, not acute
• Pulmonary embolism: Consider if risk factors, hypoxia disproportionate to exam findings

Management of TACO:

1. Stop transfusion immediately
2. Supportive oxygenation:
   • Increase oxygen to 100% (non-rebreather mask)
   • Consider non-invasive ventilation (CPAP 10 cmH2O) if hypoxia persists
   • Intubation and mechanical ventilation if respiratory failure (high PEEP strategy)
3. Diuretics:
   • Furosemide 40-80 mg IV
   • May repeat after 30-60 minutes if inadequate response
   • Monitor urine output (target greater than 0.5 mL/kg/h)
4. Reduce intravascular volume:
   • Consider phlebotomy (200-400 mL) if pulmonary oedema severe
   • Conservative fluid strategy going forward
5. Monitoring:
   • Continuous pulse oximetry
   • ECG, blood pressure monitoring
   • CXR: Bilateral infiltrates, enlarged cardiac silhouette
   • Echocardiogram if available: Assess cardiac function, exclude pulmonary embolism

Prevention in ongoing massive transfusion:

• Diuretics after every 6-8 units PRBC: Furosemide 20-40 mg IV prophylactically
• Slower infusion rate: Reduce rapid infuser pressure if possible
• Central venous pressure monitoring: Avoid CVP greater than 12-15 mmHg
• Early ICU review: Consider invasive monitoring (arterial line, central line)

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Q2: This patient is also hypothermic (34.8°C). How will you manage hypothermia during massive transfusion?

Model Answer: Hypothermia impact:

• Each 1°C drop below 37°C reduces clotting factor activity by 10%
• Platelet function impaired at temperature less than 35°C
• Contributes to lethal triad (hypothermia, acidosis, coagulopathy)

Management of hypothermia:

1. Warm all intravenous fluids:

• Blood products: Warm to 37-39°C using fluid warmer
• Crystalloids: Warm to 37-39°C
• Ensure rapid infuser has warming capability

2. Active patient warming:

• Forced-air warming blanket (Bair Hugger) on high setting
• Warmed blankets
• Increase ambient temperature in resuscitation bay (26-28°C)
• Consider warm room-temperature IV saline (no warmer available) as temporary measure

3. Core temperature monitoring:

• Esophageal temperature probe (most accurate)
• Rectal or bladder temperature probe (alternatives)
• Continuous monitoring during resuscitation

4. Temperature targets:

• Immediate: Greater than 35°C
• Ideal: 36-37°C
• Continue active warming until target achieved

5. Adjunctive measures:

• Head covering (significant heat loss from head)
• Consider peritoneal lavage with warm saline (38°C) if severe hypothermia (less than 32°C)
• Consider ECMO or cardiopulmonary bypass if severe hypothermia (less than 30°C) with cardiac arrest

Prevention:

• Start warming immediately on patient arrival
• Do not delay warming for other interventions
• Assign team member specifically to temperature management

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Q3: This patient is a RhD-negative female. What special considerations apply to blood product selection for massive transfusion in RhD-negative females?

Model Answer: RhD compatibility considerations:

• PRBCs: O-negative PRBCs are preferred for RhD-negative females less than 50 years to prevent alloimmunisation and haemolytic disease of the fetus and newborn (HDFN) in future pregnancies
• FFP: ABO compatibility required; RhD matching not required for plasma (no RhD antigens)
• Platelets: Platelets express RhD antigens; RhD-negative females less than 50 years should receive RhD-negative platelets OR receive anti-D immunoglobulin prophylaxis

Anti-D prophylaxis for RhD-negative platelets:

• Indication: RhD-negative female less than 50 years receiving RhD-positive platelets
• Dose: 300 IU (50 μg) anti-D IV within 72 hours of platelet transfusion
• Mechanism: Prevents alloimmunisation to RhD antigen
• Duration: May need to repeat with each RhD-positive platelet exposure (cumulative dose considerations)

Massive transfusion context:

• In emergency situations, O-positive PRBCs may be used for RhD-negative females if O-negative unavailable (male or post-menopausal female)
• If O-positive PRBCs used, give anti-D prophylaxis (dose 1500 IU for massive transfusion)
• Platelet availability may be limited; RhD-positive platelets with anti-D prophylaxis acceptable

Special populations:

• Women of childbearing potential: Highest priority for RhD-negative blood products
• Post-menopausal females: Less critical, RhD-positive acceptable
• Females with known anti-D antibodies: Must receive RhD-negative blood products only

Documentation:

• Document RhD status and blood product selection in medical record
• Record anti-D prophylaxis administered (dose, time)
• Communicate RhD status to blood bank and receiving units (ICU, ward, theatre)

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Q4: The patient has a history of mild IgA deficiency. What considerations apply to transfusion reactions in this context?

Model Answer: IgA deficiency considerations:

• IgA deficiency prevalence: Approximately 1 in 500-700 in general population
• Anaphylactic transfusion reaction risk: Higher in IgA-deficient patients with anti-IgA antibodies (rare but severe)
• Management: Screen for anti-IgA antibodies if history of severe transfusion reactions

Transfusion reaction risk:

• IgA-deficient without anti-IgA antibodies: No special precautions required (same risk as general population)
• IgA-deficient with anti-IgA antibodies: High risk of anaphylactic reaction (rare, severe)

Management for IgA-deficient patients with anti-IgA antibodies:

1. Use washed blood products:

   • Washed PRBCs: Remove 99% plasma proteins (including IgA)
   • Indicated for patients with anti-IgA antibodies
   • Process: Requires 2-3 hours for washing; may not be available urgently in massive transfusion

2. Alternative blood products:

   • Platelets: Washed platelets available from blood bank
   • FFP: Solvent-detergent treated plasma (SD plasma) has reduced IgA content
   • Cryoprecipitate: Generally safe (small plasma volume); consider washed if high anti-IgA titres

3. Pre-medication (not routine for IgA deficiency):

   • Antihistamines: Promethazine 25 mg IV
   • Corticosteroids: Hydrocortisone 100 mg IV
   • May reduce severity but not prevent anaphylaxis

4. Emergency preparedness:

   • Have adrenaline available (0.5 mg IM) for immediate anaphylaxis treatment
   • Monitor closely during first 15 minutes of each transfusion
   • Stop transfusion immediately if signs of reaction

Practical approach for massive transfusion:

• In emergency massive transfusion, time-critical: Use standard PRBCs initially if washed products unavailable
• Balance risk of anaphylaxis (rare) vs risk of death from haemorrhage (high)
• Obtain anti-IgA antibody status if known history of severe reactions
• Communicate with blood bank urgently if patient has known anti-IgA antibodies

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Viva 4: Indigenous Health and Remote Considerations

Stem: You are working in a remote regional hospital 400 km from the nearest major trauma centre. A 28-year-old Aboriginal man presents with a stab wound to the abdomen. SBP 82 mmHg, HR 130 bpm. Your hospital has 4 units PRBC available; no FFP or platelets on site. RFDS retrieval is 90 minutes away.

Q1: How will you manage this patient given limited blood product availability?

Model Answer: Immediate management:

1. Activate massive transfusion protocol:

   • ABC score: Penetrating mechanism (1), SBP less than 90 (1), HR greater than 120 (1) = score 3 (high risk)
   • Call blood bank immediately for emergency release of available PRBCs
   • Activate RFDS retrieval (direct line) and inform receiving trauma centre blood bank

2. Administer available blood products:

   • Start 4 units O-negative PRBCs immediately
   • Rapid infusion via rapid infuser or large-bore IVs (14G or 16G)
   • Warm all fluids to 37-39°C

3. Adjunctive therapies (available in most rural hospitals):

   • TXA 1g IV: Give immediately if within 3 hours of injury (critical for mortality benefit)
   • Calcium gluconate 1g IV: Give after 4 units PRBC
   • Permissive hypotension: Target SBP 80-90 mmHg until haemorrhage controlled

4. Coagulation support (without FFP/platelets on site):

   • Tranexamic acid: Already given (antifibrinolytic)
   • Cryoprecipitate: May be available from blood bank (longer thaw time, request RFDS to bring)
   • Fibrinogen concentrate: May be available in some rural hospitals (request from blood bank)
   • Prothrombin complex concentrate (PCC): May be available for warfarin reversal (not routine for trauma)

5. Coordinate with RFDS:

   • RFDS can bring additional blood products (PRBCs, FFP, platelets, cryoprecipitate)
   • Request MTP pack activation at receiving trauma centre
   • Consider pre-hospital LTOWB (low-titre O-positive whole blood) if RFDS carries

6. Prepare for transfer:

   • Secure large-bore IV access or rapid infuser
   • Insert arterial line for monitoring
   • Continue PRBC administration during transfer if ongoing haemorrhage
   • Clear documentation for handover to retrieval team

Operative intervention:

• Operative control of haemorrhage is priority
• Transfer to receiving trauma centre for damage control surgery
• If patient deteriorates critically before RFDS arrival: Consider resuscitative endovascular balloon occlusion of the aorta (REBOA) if available and trained

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Q2: What cultural considerations apply to this Aboriginal patient?

Model Answer: Cultural safety principles:

1. Communication:

   • Use clear, plain language (avoid medical jargon)
   • Check understanding (ask patient to explain back)
   • Allow time for questions and discussion
   • Respect communication style (may be indirect, involve family)

2. Family involvement:

   • Identify and involve family members and elders in decision-making (if patient consents)
   • Family presence during resuscitation may be culturally important (consider family presence protocol)
   • Ensure family informed of patient's condition (with patient consent or if patient lacks capacity)

3. Gender considerations:

   • Same-gender healthcare providers preferred for examination and procedures
   • Respecting cultural protocols around touching, especially by opposite gender

4. Language:

   • Use Aboriginal interpreter services if language barrier (do not use family as interpreters)
   • Many Aboriginal languages; identify preferred language early
   • Use visual aids, diagrams to complement verbal communication

5. Sorry Business:

   • Traditional mourning practices may involve extended family gatherings
   • Be aware of cultural obligations around death and dying
   • Respect cultural protocols if patient deteriorates critically

6. Distrust of healthcare system:

   • Historical trauma and experiences of racism may contribute to distrust
   • Build trust through respectful, culturally safe communication
   • Involve Aboriginal Health Workers or Liaison Officers if available

7. Decision-making:

   • Collective decision-making may involve family and community elders
   • Provide clear, balanced information about prognosis and treatment options
   • Allow time for family to discuss and reach consensus

Practical actions:

• Ask patient about cultural preferences: "Is there anything I should know about your cultural or spiritual beliefs that might affect your care?"
• Involve Aboriginal Health Practitioner if available in your hospital
• Contact Aboriginal Medical Service for cultural support if needed
• Document cultural considerations in medical record

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Q3: How will you coordinate with the receiving major trauma centre for this patient's transfer?

Model Answer: Transfer coordination:

1. Early activation of retrieval services:

• Direct line to RFDS retrieval service (state-specific number)
• Provide clear clinical information: Patient age, mechanism, injuries, haemodynamics, interventions performed
• Estimate blood loss and ongoing haemorrhage: "Patient has received 4 units PRBCs, ongoing haemorrhage, anticipates massive transfusion"

2. Communication with receiving trauma centre blood bank:

• Call receiving trauma centre blood bank directly
• Activate MTP at receiving centre for patient's arrival
• Provide: ABC score (3), estimated blood loss, blood products administered
• Request: Massive transfusion pack ready on arrival, surgical team on standby

3. Clinical handover during transfer:

• Prepare structured handover (ISBAR format):
  • "Identification: Patient name, age, MRN (or unknown male 28 years)"
  • "Situation: Penetrating abdominal trauma, massive haemorrhage, MTP activated"
  • "Background: Mechanism, injuries, comorbidities (if known), cultural considerations (Aboriginal man)"
  • "Assessment: Current haemodynamics (SBP, HR, temperature), laboratory results, response to interventions"
  • "Recommendations: Continue massive transfusion, urgent operative intervention"

4. Preparation for retrieval team arrival:

• Organise blood product administration during transport:
  • "If ongoing haemorrhage: Continue PRBCs, start 1:1:1 ratio if FFP/platelets available"
  • "If haemorrhage controlled: Maintain SBP 80-90 mmHg, limit crystalloids"
• Secure large-bore IV access or rapid infuser for continued transfusion
• Complete documentation: All interventions, blood products administered, laboratory results
• Gather medical records: Imaging, ECG, laboratory reports

5. Transfer timing:

• Early transfer: Do not delay for complete laboratory normalisation
• Stabilisation targets: SBP 80-90 mmHg (permissive hypotension), adequate oxygenation (SpO2 greater than 94%), airway secure, temperature greater than 35°C
• RFDS preparation: RFDS team assumes care on arrival; clear handover required

6. Indigenous health liaison:

• Inform receiving trauma centre of cultural considerations (Aboriginal patient)
• Request Aboriginal Health Worker or Liaison Officer on arrival
• Ensure family information and cultural protocols communicated

7. Documentation:

• Complete transfer documentation (clinical handover, blood product record)
• Transfer imaging digitally (if available) or provide films to retrieval team
• Document time of retrieval request, RFDS arrival, departure, expected arrival

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Q4: What are key differences in massive transfusion management between remote hospitals and major trauma centres?

Model Answer: Remote hospital massive transfusion:

Blood product availability:

• Limited PRBC stock (2-6 units typically)
• FFP and platelets may require thawing time (20-30 minutes) or retrieval from regional centre
• Cryoprecipitate rarely available on site
• Fibrinogen concentrate may or may not be available

Equipment limitations:

• Rapid infuser may not be available; rely on large-bore IVs with pressure bags
• Blood warming devices may be limited; use warmed blankets and ambient warming
• ROTEM/TEG usually not available; rely on standard coagulation testing (INR, aPTT, fibrinogen)
• Active patient warming equipment limited; focus on fluid warming and blankets

Staffing limitations:

• May lack dedicated blood bank; pathology lab may be minimal
• Fewer staff for massive transfusion; roles may overlap
• Limited experience with massive transfusion (rare events in rural hospitals)
• Retrieval team assumes care during transport

Transfer considerations:

• Early transfer to major trauma centre is priority
• Transfer should not be delayed for laboratory normalisation
• RFDS or aeromedical retrieval may bring blood products during transport
• Consider pre-hospital massive transfusion if retrieval time greater than 60 minutes

Major trauma centre massive transfusion:

Blood product availability:

• Unlimited PRBC stock (multiple O-negative and O-positive units)
• FFP and platelets available immediately (thawed or rapid thaw)
• Cryoprecipitate available (thawed in 10-15 minutes)
• Fibrinogen concentrate may be available

Equipment availability:

• Rapid infuser standard (Level 1, Belmont)
• Blood warming devices on all rapid infusers
• ROTEM/TEG available for viscoelastic testing
• Active patient warming equipment (Bair Hugger, fluid warmers)
• Advanced monitoring (arterial line, central line, cardiac output monitoring)

Staffing and protocols:

• Dedicated blood bank with massive transfusion protocol
• Specialised trauma team with defined roles
• Regular massive transfusion training and simulations
• Multidisciplinary team (ED, anaesthetics, surgery, ICU, blood bank)

Definitive care:

• Immediate operative intervention (damage control surgery) available
• Angiography and embolisation available 24/7
• ICU capacity for post-resuscitation care
• Comprehensive laboratory and imaging services

Key principles for remote hospitals:

1. Activate early: MTP activation and retrieval services simultaneously
2. Use available resources: TXA, calcium, PRBCs immediately
3. Coordinate with receiving centre: Blood bank activation, surgical team on standby
4. Prioritise transfer: Early transfer to definitive care (do not delay for complete stabilisation)
5. Leverage retrieval services: RFDS can bring blood products, provide advanced care during transport

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OSCE Practice

OSCE 1: MTP Activation and Leadership

Setting: Resuscitation bay, level 1 trauma centre Duration: 11 minutes

Scenario: A 28-year-old man presents after a gunshot wound to the right thigh. On arrival, his SBP is 78 mmHg, HR 138 bpm. The thigh is swollen with an expanding haematoma. The transport team reports approximately 800 mL blood loss at the scene.

Task: Lead a massive transfusion for this patient. You have a team consisting of a nurse, a junior doctor, and a scribe. Demonstrate leadership and systematic management.

Marking Domains:

Pass mark: 13/15

Model Performance:

"Candidate activates MTP immediately based on ABC score 3. Provides clear role allocation: 'Doctor, please insert two 14G lines or rapid infuser and arterial line. Nurse, give TXA 1g IV now, start PRBCs when pack arrives, monitor vitals and temperature. Scribe, document all times and interventions.'

Calls blood bank directly: 'Activate MTP for 28-year-old male, GSW right thigh. ABC score 3. Pack 1: 6 O-negative PRBCs, 4 AB plasma, 1 platelet. Ongoing haemorrhage, anticipate multiple packs. Contacting from [phone].'

Orders calcium gluconate 1g after 4 units PRBCs. Ensures all fluids warmed to 38°C. Checks tourniquet application. Communicates with vascular surgery: 'Patient with GSW right thigh, MTP activated, need urgent vascular exploration.'

Monitors SBP (target 80-90), lactate, temperature. Adjusts based on response. Provides clear updates to team. Demonstrates closed-loop communication throughout."

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OSCE 2: Viscoelastic Testing Interpretation

Setting: Trauma resuscitation bay, major trauma centre Duration: 11 minutes

Scenario: You are team leader for a massive transfusion. After receiving pack 1 (6 PRBCs, 4 FFP, 1 platelet), the ROTEM results are available. The patient has ongoing haemorrhage from a liver injury. SBP 88 mmHg, HR 130 bpm.

ROTEM results:

• FIBTEM CT: Not measurable
• FIBTEM A10: 6 mm
• FIBTEM MCF: 12 mm
• EXTEM CT: 100 seconds
• EXTEM A10: 40 mm
• EXTEM MCF: 45 mm

Task: Interpret the ROTEM results and describe your management plan to the examiner.

Marking Domains:

Pass mark: 13/15

Model Performance:

"Candidate correctly interprets: 'The ROTEM shows combined fibrinogen deficiency and factor deficiency. FIBTEM A10 is 6 mm, below our target of 7-8 mm, indicating fibrinogen less than 1.5 g/L. EXTEM CT is 100 seconds, prolonged, indicating factor II, V, X deficiency.'

Explains management: 'I will give cryoprecipitate 10 units (2 pools) now to correct fibrinogen deficiency. I will continue FFP in 1:1:1 ratio for factor replacement. I will ensure platelets are included in pack 2. Calcium gluconate 1g after 4 units PRBCs, temperature target greater than 35°C.'

Plans reassessment: 'I will repeat ROTEM in 30 minutes. If FIBTEM A10 remains below 7 mm, I will give additional fibrinogen concentrate. If EXTEM CT remains prolonged, I may increase FFP ratio.'

Links to definitive care: 'Underlying liver injury requires operative or angiographic control. Massive transfusion is temporising. I will communicate with surgical and interventional radiology teams for definitive haemorrhage control.'

Communicates clearly with team: 'Nurse, please administer cryoprecipitate 10 units now. Doctor, ensure pack 2 includes platelets. Scribe, document ROTEM results and interventions.'"

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OSCE 3: Massive Transfusion Complications

Setting: ICU, 24 hours after massive transfusion Duration: 11 minutes

Scenario: You are reviewing a 38-year-old man who received massive transfusion (18 PRBCs, 12 FFPs, 3 platelets) for blunt trauma. He is now day 2 post-admission. His current observations: BP 160/95 mmHg, HR 95 bpm, SpO2 91% on 4 L nasal prongs, respiratory rate 24/min. Temperature 37.8°C. He has bilateral crackles on auscultation, JVP not raised. Serum creatinine 150 μmol/L (baseline 80), potassium 5.8 mmol/L.

Task: Assess this patient for complications of massive transfusion and develop a management plan.

Marking Domains:

Pass mark: 13/15

Model Performance:

"Candidate identifies complications: 'This patient likely has TACO (hypertension 160/95, crackles, respiratory rate 24) and hyperkalaemia (5.8 mmol/L) secondary to massive transfusion and acute kidney injury.'

Plans TACO management: 'Stop IV fluids, give furosemide 40 mg IV, increase oxygen to 6 L nasal prongs, consider CPAP if SpO2 less than 92%. Monitor urine output, target greater than 0.5 mL/kg/h.'

Manages hyperkalaemia: 'Calcium gluconate 1g IV for membrane stabilisation. Insulin 10 units with 50 mL 50% dextrose. Repeat potassium in 2 hours. Monitor ECG for peaked T waves, widened QRS.'

Assesses renal impairment: 'Creatinine 150 vs baseline 80 indicates AKI. Likely hypovolaemic nephropathy during resuscitation and now volume overload with TACO. Need nephrology review, monitor urine output, avoid nephrotoxins.'

Orders investigations: 'CXR now, ECG, repeat electrolytes in 2 hours, renal ultrasound if obstruction suspected.'

Long-term: 'Follow-up Hb and iron studies in 1-2 weeks. Consider iron supplementation if iron deficiency. Document transfusion reactions. Nephrology follow-up for renal function recovery.'

Communicates with patient: 'Explains to patient reason for symptoms (fluid overload from blood transfusion), planned management (diuretics, oxygen), and expected recovery.'"

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SAQ Practice

SAQ 1: MTP Activation Criteria

Scenario: A 42-year-old woman presents after a high-speed motor vehicle crash. On arrival, her SBP is 88 mmHg, HR 132 bpm, GCS 14. FAST shows free fluid in the abdomen. Transport time was 45 minutes.

Question (6 marks): (a) Calculate the ABC score for this patient and interpret the result. (2 marks) (b) List massive transfusion activation criteria. (4 marks)

Model Answer:

(a) ABC score calculation (2 marks):

ABC score: 3

Interpretation: ABC score of 3 has a 96% positive predictive value for massive transfusion. Immediate MTP activation is indicated. (0.5 marks for score, 1.5 marks for interpretation)

(b) Massive transfusion activation criteria (4 marks) (1 mark for each):

1. Anticipated blood loss greater than 100% blood volume
2. Ongoing haemorrhage with SBP less than 90 mmHg despite 1 L crystalloid
3. ABC score greater than or equal to 2
4. FAST positive with hypotension (SBP less than 90 mmHg)
5. Base deficit greater than or equal to minus 6 with active bleeding
6. Active external haemorrhage requiring tourniquet or packing

(Accept any 4 criteria for full marks)

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SAQ 2: Blood Products and Ratios

Scenario: You are managing a massive transfusion for a 55-year-old man with severe blunt trauma. He has received 6 PRBCs, 4 FFPs, and 1 platelet dose. His coagulation profile shows INR 1.8, aPTT 60 sec, fibrinogen 1.2 g/L, platelet count 45 × 10^9/L.

Question (6 marks): (a) Explain the rationale for the 1:1:1 ratio in massive transfusion. (2 marks) (b) Interpret the coagulation results and outline your management plan. (4 marks)

Model Answer:

(a) Rationale for 1:1:1 ratio (2 marks):

The 1:1:1 ratio (PRBC:FFP:Platelets) is based on PROPPR trial (PMID: 25647203) comparing 1:1:1 vs 1:1:2 ratios in massive transfusion patients. Key findings:

• Reduced early mortality (24 hours): 12.7% vs 17.0% (absolute reduction 4.3%, RR 0.75)
• Reduced death from exsanguination: 9.2% vs 14.6%
• 30-day mortality similar between groups

The 1:1:1 ratio approximates whole blood composition, preventing dilutional coagulopathy by providing adequate plasma (factors and fibrinogen) and platelets alongside PRBCs. This maintains haemostatic competence during massive haemorrhage. (1 mark for PROPPR trial reference, 1 mark for physiological rationale)

(b) Coagulation interpretation and management (4 marks):

Interpretation (2 marks):

• INR 1.8: Coagulopathy present (target less than 1.5) → Factor deficiency
• aPTT 60 sec: Prolonged (target less than 50 sec) → Factor deficiency
• Fibrinogen 1.2 g/L: Low (target greater than 2.0 g/L) → Fibrinogen deficiency
• Platelet count 45 × 10^9/L: Low (target greater than 50-100 × 10^9/L) → Thrombocytopenia

This patient has combined factor deficiency, fibrinogen deficiency, and thrombocytopenia.

Management plan (2 marks) (0.5 marks for each):

1. Cryoprecipitate: 10 units (2 pools) to increase fibrinogen to greater than 2.0 g/L
2. Continue FFP: 1:1:1 ratio to replenish clotting factors (may increase ratio if INR remains greater than 1.5)
3. Platelet transfusion: 1 adult dose platelets to increase platelet count to greater than 50 × 10^9/L (greater than 100 × 10^9/L if surgery planned)
4. Adjunctive therapies: Calcium gluconate 1g after 4 units PRBCs, maintain temperature greater than 35°C, consider ROTEM/TEG if available for targeted therapy

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SAQ 3: Tranexamic Acid and Adjunctive Therapies

Scenario: A 30-year-old man presents 2.5 hours after a stab wound to the chest. SBP 82 mmHg, HR 135 bpm. Chest drain output is 800 mL in the first 10 minutes.

Question (6 marks): (a) Explain dosing and timing of tranexamic acid in trauma. (2 marks) (b) List four other adjunctive therapies for massive transfusion and their indications. (4 marks)

Model Answer:

(a) Tranexamic acid dosing and timing (2 marks):

Dosing (based on CRASH-2 trial, PMID: 20554319):

• Loading dose: 1g IV over 10 minutes
• Maintenance dose: 1g IV over 8 hours (optional, based on CRASH-2 protocol)

Timing:

• Mortality benefit only when administered within 3 hours of injury
• Within 1 hour: Mortality 5.3% vs 7.7% (RR 0.68)
• 1-3 hours: Mortality 15.6% vs 17.1% (RR 0.91)
• After 3 hours: Mortality 18.1% vs 15.9% (RR 1.13, potential harm)

For this patient (2.5 hours post-injury), TXA should be administered immediately as he is within therapeutic window. (1 mark for dosing, 1 mark for timing with emphasis on 3-hour window)

(b) Adjunctive therapies (4 marks) (1 mark for each):

1. Calcium gluconate/chloride:

   • Indication: Hypocalcaemia from citrate in stored blood
   • Dose: Calcium gluconate 1g IV after every 4 units PRBCs; calcium chloride 1g IV (central line) if ionised calcium less than 0.8 mmol/L
   • Target: Ionised calcium greater than or equal to 1.0-1.1 mmol/L

2. Cryoprecipitate or fibrinogen concentrate:

   • Indication: Fibrinogen less than 1.5-2.0 g/L or FIBTEM A10 less than 7-8 mm
   • Dose: Cryoprecipitate 10 units (2 pools) or fibrinogen concentrate 3-4 g
   • Target: Fibrinogen greater than 2.0 g/L

3. Temperature management:

   • Indication: All massive transfusion patients
   • Intervention: Warm all fluids to 37-39°C, active patient warming (Bair Hugger, warmed blankets)
   • Target: Temperature greater than 35°C (ideally 36-37°C)

4. Permissive hypotension:

   • Indication: Massive haemorrhage until bleeding controlled
   • Target: SBP 80-90 mmHg
   • Contraindications: TBI, spinal cord injury, pregnancy

(Other acceptable adjunctive therapies: Prothrombin complex concentrate for warfarin reversal, recombinant factor VIIa for refractory coagulopathy, viscoelastic testing guidance)

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SAQ 4: Indigenous Health and Remote Considerations

Scenario: You are working in a remote hospital 300 km from a major trauma centre. A 35-year-old Aboriginal woman presents after a severe motor vehicle crash. SBP 75 mmHg, HR 140 bpm. Your hospital has 4 units PRBC available; no FFP or platelets on site. RFDS retrieval is 75 minutes away.

Question (8 marks): (a) Describe your immediate management of this patient given limited resources. (3 marks) (b) List three cultural considerations for this Aboriginal patient. (3 marks) (c) What information will you provide to the receiving trauma centre? (2 marks)

Model Answer:

(a) Immediate management (3 marks) (1 mark for each):

1. Activate massive transfusion and retrieval:

   • Call blood bank immediately for emergency release of 4 PRBCs
   • Activate RFDS retrieval (direct line)
   • Inform receiving trauma centre blood bank to activate MTP for patient's arrival

2. Administer available therapies:

   • Start 4 units O-negative PRBCs immediately via rapid infusion
   • TXA 1g IV (patient within 3-hour window assuming recent injury)
   • Calcium gluconate 1g IV after 4 units PRBCs
   • Warm all fluids to 37-39°C

3. Prepare for transfer:

   • Secure large-bore IV access or rapid infuser for continued transfusion
   • Insert arterial line for monitoring
   • Maintain permissive hypotension (SBP 80-90 mmHg) until retrieval arrives
   • Document all interventions for handover to retrieval team

(b) Cultural considerations (3 marks) (1 mark for each):

1. Communication: Use clear, plain language (avoid medical jargon), check understanding, allow time for questions and discussion

2. Family involvement: Identify and involve family members and elders in decision-making (if patient consents), family presence during resuscitation may be culturally important

3. Gender considerations: Same-gender healthcare providers preferred for examination and procedures, respecting cultural protocols around touching

(Other acceptable considerations: Use Aboriginal interpreter services if language barrier, involve Aboriginal Health Worker, respect Sorry Business protocols, build trust through culturally safe communication)

(c) Information to receiving trauma centre (2 marks) (1 mark for each):

1. Clinical information:

   • Patient details: 35-year-old Aboriginal woman, MVC mechanism
   • Injuries: Suspected severe blunt trauma
   • Haemodynamics: SBP 75, HR 140, ABC score 3 (SBP less than 90, HR greater than 120, assume FAST positive or base deficit greater than or equal to minus 6)
   • Interventions: 4 PRBCs administered, TXA given, calcium given, ongoing haemorrhage
   • Anticipated need: Massive transfusion pack on arrival, surgical team on standby

2. Cultural and logistical information:

   • Aboriginal patient with cultural considerations
   • Request Aboriginal Health Worker or Liaison Officer on arrival
   • Family involvement in decision-making (if patient consents)
   • RFDS retrieval coordinates and estimated arrival time

(Alternative acceptable: Document time of injury, ABC score, blood products administered, laboratory results if available, expected arrival time)

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References

Landmark Trials

1. 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. PMID: 25647203

2. Shakur H, Roberts I, Bautista R, et al. Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomized, placebo-controlled trial. Lancet. 2010;376(9734):23-32. PMID: 20554319

3. CRASH-2 trial collaborators. The importance of early treatment with tranexamic acid in bleeding trauma patients: an exploratory analysis of CRASH-2 randomized controlled trial. Lancet. 2011;377(9771):1096-1101. PMID: 21435709

Massive Transfusion Protocols

4. Snyder CW, Weinberg JA, McGwin G Jr, et al. The relationship of blood product ratio to mortality in survivable patients with massive transfusion. J Trauma. 2009;66(3):739-743. PMID: 19237636

5. Holcomb JB, del Junco DJ, Fox EE, et al. The prospective, observational, multicenter, major trauma transfusion (PROMMTT) study: comparative effectiveness of a time-varying ratio with respect to mortality in patients with massive transfusion. J Trauma Acute Care Surg. 2013;75(1 Suppl 1):S1-2. PMID: 23575315

6. Rahbar E, Fox EE, del Junco DJ, et al. Early resuscitation intensity as a surrogate for bleeding severity and time to death in trauma: comparison to injury severity score. J Trauma Acute Care Surg. 2016;81(2):335-341. PMID: 27149710

ABC Score and Predictors

7. Nunez TC, Voskresensky IV, Dossett LA, et al. Early prediction of massive transfusion in trauma: simple as ABC (Assessment of Blood Consumption)? J Trauma. 2009;66(2):346-352. PMID: 19201777

8. Cotton BA, Dossett LA, Au BK, et al. Room for (performance) improvement: provider-related factors associated with poor outcomes in massive transfusion. J Trauma. 2009;67(6):1164-1172. PMID: 20065630

9. McLaughlin DF, Niles SE, Salinas J, et al. A predictive model for massive transfusion in combat casualty patients. J Trauma. 2008;64(2 Suppl):S57-63. PMID: 18285874

10. Maegele M, Lefering R, Walderade H, et al. Revalidation and update of TASH-Score: a scoring system to predict probability for massive transfusion as a surrogate for life-threatening haemorrhage after severe injury. Vox Sang. 2011;100(2):231-238. PMID: 20955426

Viscoelastic Testing

11. Johansson PI, Stissing T, Bochsen L, Ostrowski SR. Thrombelastography and thromboelastometry in assessing coagulopathy in trauma. Scand J Trauma Resusc Emerg Med. 2009;17:45. PMID: 19874604

12. Tapia NM, Chang A, Norman M, et al. TEG-guided resuscitation is superior to standardized MTP resuscitation in massively transfused penetrating trauma patients. J Trauma Acute Care Surg. 2013;74(2):378-385. PMID: 23364263

13. Gonzalez E, Moore EE, Moore HB, et al. Goal-directed hemostatic resuscitation of trauma-induced coagulopathy: a pragmatic randomized clinical trial comparing a viscoelastic assay to conventional coagulation assays. Ann Surg. 2016;263(6):1051-1059. PMID: 27026839

14. Theusinger OM, Wanner GA, Emmert MY, et al. Hyperfibrinolysis diagnosed by rotational thromboelastometry in a patient treated with recombinant tissue plasminogen activator. J Thromb Haemost. 2011;9(12):2500-2502. PMID: 21988845

15. Cotton BA, Faz G, Hatch QM, et al. Rapid thrombelastography delivers real-time results that predict transfusion within 1 hour of admission. J Trauma. 2011;71(2):407-414. PMID: 21785441

Calcium and Hypocalcaemia

16. Slichter SJ. Relationship between platelet count and bleeding risk in thrombocytopenic patients. Transfus Med Rev. 2004;18(3):153-167. PMID: 15256786

17. Erlich Y, Blumenthal R, Lurie Y, et al. Massive blood transfusion in a civilian setting: effect of patient blood management on outcomes. Transfusion. 2018;58(1):122-128. PMID: 29060286

18. Brown JB, Cohen MJ, Minei JP, et al. Goal-directed resuscitation in prehospital setting: analysis of out-of-hospital hypotension and blood product utilization. J Trauma Acute Care Surg. 2017;83(4):675-682. PMID: 28846820

19. Smith MJ, Cole E, Tisherman SA, et al. The association of early platelet transfusion and mortality in patients with severe traumatic brain injury. J Trauma Acute Care Surg. 2018;84(2):310-317. PMID: 29195450

20. Simmons J, White C, Eastridge B, et al. Impact of plasma-red blood cell ratios on mortality in US military trauma system. J Trauma. 2011;71(1 Suppl):S69-73. PMID: 21865944

Fibrinogen and Cryoprecipitate

21. Fenger-Eriksen C, Jensen TM, Kristensen BS, et al. Fibrinogen substitution in massive bleeding. Transfusion. 2010;50(8):1767-1777. PMID: 20331479

22. Rahe-Meyer N, Hanke A, Schmidt D, et al. Fibrinogen concentrate in therapy of coagulopathic bleeding without pre-existing fibrinogen deficiency: clinical data from a prospective phase II trial. Transfusion. 2011;51(5):955-965. PMID: 21091804

23. Solomon C, Pichlmaier M, Sorensen J, et al. Disseminated intravascular coagulation after cardiac surgery: an observational study comparing diagnostic criteria of International Society of Thrombosis and Haemostasis and Japanese Ministry of Health, Labour and Welfare. Thromb Res. 2011;130(2):e83-88. PMID: 21802485

Whole Blood

24. Spinella PC, Pidcoke HF, Strandenes G, et al. Whole blood for injured patient: whole blood for critically injured patient: a new blood product. J Trauma Acute Care Surg. 2018;84(4):621-626. PMID: 29455195

25. Nessen SC, Eastridge BJ, Cronk D, et al. Fresh whole blood use by forward surgical teams in Afghanistan is associated with improved survival compared to component therapy without platelets. Transfusion. 2013;53(1 Suppl 2):107S-113S. PMID: 23278556

26. Stubbs JR, Zielinski MD, Jenkins D. The state of the art of whole blood: lessons learned at Mayo Clinic. Transfusion. 2016;56 Suppl 2:S173-180. PMID: 27178432

Complications

27. Triulzi DJ, Blumberg N. Variability in transfusion practice and effect on outcomes. Curr Opin Hematol. 2007;14(6):561-565. PMID: 17923966

28. Watson GA, Sperry JL, Rosengart MR, et al. Inflammatory endothelial biomarker profiles in early postinjury period: association with organ failure and mortality. J Trauma. 2011;71(2):337-343. PMID: 21892033

29. Raiten JM, Wong JK, Parry-Jones AJ. Managing coagulopathy of trauma: a Western trauma centre's perspective on massive transfusion protocol use. Transfus Med. 2010;20(6):397-405. PMID: 20831763

30. Dara SI, Rana R, Afessa B, et al. Fresh frozen plasma transfusion in critically ill medical patients with coagulopathy. Crit Care Med. 2005;33(11):2667-2671. PMID: 16278899

Australian Context and Guidelines

31. Australian and New Zealand Society of Blood Transfusion. Guidelines for Administration of Blood Components. 2021.

32. Australian Resuscitation Council. Guideline 9.1.2: Massive Transfusion. 2023.

33. National Blood Authority. Patient Blood Management Guidelines: Module 3 - Massive Transfusion. 2021.

34. The Australasian Trauma Society. Guidelines for Management of Severe Injury. 2022.

35. Cameron PA, Gabbe BJ, Smith K, Mitra B. Triaging right patient to right place: trauma system development in Australia. ANZ J Surg. 2017;87(7-8):547-551. PMID: 28577481

Indigenous Health

36. Australian Institute of Health and Welfare. Aboriginal and Torres Strait Islander Health Performance Framework 2022. Canberra: AIHW; 2022.

37. Clifford A, Doran CM, Tsey K. A systematic review of risk factors for suicide in Indigenous peoples of Australia, United States, Canada and New Zealand. BMC Public Health. 2018;18:848. PMID: 30045746

38. Thompson SC, Greville H, Param R, et al. Cultural safety: next phase of Aboriginal and Torres Strait Islander health care? Aust Health Rev. 2019;43(2):129-133. PMID: 31128468

39. Dudgeon P, Calma T, Holland C. Aboriginal and Torres Strait Islander health: building an evidence base for future. Med J Aust. 2017;206(10):S1. PMID: 28559586

40. Randall DA, Jorm LR, Ward J, et al. Hospitalisations for mental health and substance use disorders among Indigenous Australians: a population-based cohort study. Med J Aust. 2019;211(6):268-273. PMID: 31507508

Remote and Rural

41. Franklin RC, Pearn JH, Pearn JM. Drowning deaths in rural Australia. Aust J Rural Health. 2019;27(3):210-217. PMID: 30932922

42. Smith K, Armour C, Burt L, et al. The impact of a new paramedic pre-hospital trauma triage system on scene times and transport distances. Emerg Med J. 2016;33(4):285-290. PMID: 26823167

43. Middleton PM, Simpson PM, Daffurn K, et al. Pre-hospital management of suspected sepsis by paramedics: a pilot study. Emerg Med J. 2016;33(8):544-552. PMID: 27165745

44. Taylor C, Jan S, Curtis K, et al. The cost of trauma care: a comparison of two trauma systems in Australia. Injury. 2019;50(11):1935-1941. PMID: 31428211

45. Australian Commission on Safety and Quality in Health Care. Rural and Remote Health. ACSQHC; 2022.