1. First 5 minutes: simultaneous actions

1. Call for help
   • Trauma surgeon, anesthesia, blood bank, operating room.
   • State clearly: “Activate MTP. Unstable trauma, positive FAST, suspected abdominal hemorrhage.”
2. Airway and oxygen
   • Give high-flow oxygen.
   • Intubate if required, but do not cause a prolonged delay to hemorrhage control. Be prepared for peri-intubation arrest in severe hypovolemia.
3. Access
   • Two large-bore IV cannulas, ideally 14-16 G.
   • If not rapidly possible: rapid intraosseous access or large central access.
   • Use a rapid infuser and blood warmer for RBCs and plasma.
4. Send blood before large transfusion if possible
   • Type and crossmatch, CBC, PT/INR, aPTT, fibrinogen, ABG/VBG, lactate, electrolytes including ionized calcium, potassium, and blood gas.
   • Do not delay blood or surgery waiting for these results.
5. Immediate source control
   • Unstable + intraperitoneal free fluid on eFAST: go to operating theatre for emergency laparotomy.
   • If pelvic injury is possible, apply a pelvic binder over the greater trochanters while moving to theatre.

2. How to give the massive transfusion

Preferred resuscitation fluid

• Pack 1: 4 RBC + 4 FFP/plasma
• Pack 2: 4 RBC + 4 FFP/plasma + 1 adult apheresis platelet unit
• Continue packs while bleeding continues, then tailor with labs/TEG/ROTEM.

If blood group is not yet known

• RBCs: uncrossmatched group O RBCs.
  • O Rh-negative is generally prioritized for females of child-bearing potential and children.
  • O Rh-positive may be used in adult males or post-menopausal females when O-negative stock is limited, according to local policy.
• Plasma: group AB plasma or low-titer anti-B group A plasma, per local blood-bank policy.
• Change to type-specific blood as soon as the blood bank confirms group.

3. Adjuncts during MTP

Tranexamic acid

• TXA 1 g IV over 10 minutes, then
• 1 g IV over 8 hours

Calcium

• Check ionized calcium early and repeatedly.
• Keep ionized calcium in the normal range, often targeted at >1.1 mmol/L.
• Many trauma protocols give calcium empirically during active MTP, for example after about 4 units of blood products, then adjust to ionized calcium and ECG.
• Use the exact dose and formulation in your local protocol. Calcium chloride is more potent but should preferably be given through central access; calcium gluconate is safer through a peripheral line.

Fibrinogen replacement: cryoprecipitate or fibrinogen concentrate

• fibrinogen is <1.5 g/L, or
• there is viscoelastic evidence of fibrinogen deficiency, or
• severe ongoing bleeding makes a result unavailable and the protocol calls for empiric early fibrinogen replacement.

Platelets

• platelet count is <50 × 10⁹/L in active bleeding
• platelet count is <100 × 10⁹/L with traumatic brain injury or neurosurgical concern
• TEG/ROTEM suggests poor platelet contribution

If the patient uses anticoagulants

• Warfarin: use four-factor PCC plus IV vitamin K, guided by local protocol.
• Factor Xa inhibitors: consider drug-specific reversal where available or PCC according to protocol.
• Dabigatran: idarucizumab if available.
• Do not give PCC or recombinant factor VIIa routinely for traumatic bleeding without a specific indication or specialist decision.

4. What to monitor continuously

5. What to do and what not to do

Do

• Give warmed blood products promptly.
• Use a rapid infuser for RBCs and plasma.
• Continue balanced transfusion while there is uncontrolled hemorrhage.
• Keep the patient warm: forced-air warming, warm room, warm fluids/blood.
• Use damage-control surgery early.
• Communicate continuously with blood bank and operating theatre.
• Reassess after every pack and de-escalate when hemorrhage is controlled.

Do not

• Do not send this unstable, FAST-positive patient for CT.
• Do not delay laparotomy to normalize BP or laboratory values.
• Do not give large volumes of normal saline or other crystalloid. If blood is momentarily unavailable, use only small bridging boluses.
• Do not give RBCs alone repeatedly without plasma and platelets during massive hemorrhage.
• Do not use vasopressors as a substitute for blood and surgical hemorrhage control.
• Do not target a normal BP before hemostasis in a patient without traumatic brain injury.
• Do not warm platelets or cryoprecipitate through a blood warmer unless the device and local protocol specifically permit it.
• Do not stop looking for another bleeding source: chest, pelvis, long bones, external wounds, retroperitoneum.

6. Blood-pressure target

• Use permissive hypotension temporarily.
• Aim roughly for SBP 70-90 mmHg, or a palpable radial pulse and improving consciousness, until surgical control of bleeding.

Practical one-line order for this case

“Activate MTP. Give warmed uncrossmatched group O RBCs with plasma immediately in a balanced 1:1 approach, bring platelets early to achieve 1:1:1, give TXA if within 3 hours, monitor and replace calcium, obtain fibrinogen and give cryoprecipitate/fibrinogen if low, minimize crystalloid, and proceed now to damage-control laparotomy.”