Major haemorrhage protocol (MHP) template - PowerPoint Presentation

1. Major haemorrhage protocol (MHP) templateAn MHP includes a multidisciplinary approach to haemorrhage control, correction of coagulopathy and normalisation of physiological parametersSenior clinician determines patient requires MHP activationURGENT: blood group, cross match, blood gas analysis, full blood count, coagulation screen (PT, INR, APTT, fibrinogen), biochemistryNotify transfusion laboratory (insert number) ‘Activate MHP’a The numerical representation of base excess can be shown differently in varying texts. Please be aware that for the purposes of this template, a base excess of ≥-6 refers to a base excess of  -5, -4, -3 and so forth. A base excess of -7, -8, -9 and so on is associated with a worsening prognosis. The normal range for base excess is -2 - +2.Resuscitation team receives*MHP Pack 1 MHP Pack 2RBC - 4 units RBC - 4 unitsFFP - 2 units FFP - 2 unitsPLT - 1 adult unitAdd*If fibrinogen < 2 g/L: either whole blood cryoprecipitate 8 to 10 units or apheresis cryoprecipitate 4 to 5 units or fibrinogen concentrate 3 to 4 gtranexamic acid 1 g IV over 10 minutesconsider 10% calcium gluconate 10mL IV for every 4 units of RBC or if ionised calcium < 1 mmol/L*or locally agreed configurationConsider viscoelastic haemostatic assays (VHA) if part of the MHPInform transfusion laboratory if using TEG® or ROTEM®Blood components as per local VHA guided algorithmTransfusion laboratoryPrepare and issue blood components as requestedAnticipate repeat testing and blood component requirementsMinimise test turnaround timesConsider staff resourcesNotify haematologist/transfusion medicine specialist as they may be required to liaise with the clinical teamProvide group specific blood components as soon as possibleBleeding ControlledYesNotify transfusion laboratory to: ‘Cease MHP’YesOPTIMISEoxygenationcardiac outputtissue perfusionmetabolic stateMONITOR (at least every 4 units of RBC):full blood countcoagulation screenionised calciumblood gasTARGETtemperature ≥ 35◦CpH ≥ 7.2base excess ≥ -6a mEq/Llactate ≤ 4 mmol/LIonised Ca2+ ≥ 1.0 mmol/Lplatelets > 50 x 109/LPT/APTT ≤ 1.5 x normalINR ≤ 1.5fibrinogen ≥ 2.0 g/L

2. APTT: activated partial thromboplastin time, BP: blood pressure, bpm: beats per minute, Ca2+: calcium gluconate, FFP: fresh frozen plasma, INR: international normalised ratio, IU: international unit, IV: intravenous, MHP: major haemorrhage protocol, mEq/L: milliequivalents per litre, mmHg: millimetres of mercury, mmol/L: millimoles per litre, PCC: prothrombin complex concentrate, PLT: platelets, PT: prothrombin time, RBC: red blood cells, VHA: viscoelastic haemostatic assaysClinical suspicion of critical bleeding and one or more of:systolic blood pressure < 100 mmHgheart rate > 100 bpmpositive focused assessment with sonography for trauma (FAST)ongoing exsanguination, estimated blood loss > 1LpallorSuggested criteria for MHP activationIdentify causeControl bleeding, using: compressiontourniquetpacking pelvic binderSurgical assessment:early surgery or angiography to stop bleeding Initial management of bleedingInstitute active warming, avoid hypothermiaWarm blood through a blood warming device if availablePrioritise blood products over crystalloidsConsider permissive hypotension (systolic BP: 70 to 100 mmHg) ResuscitationOther considerationsWarfarin reversal:prothrombin complex concentrate (PCC) for warfarin reversal: dose 25 to 50 IU/kgrefer to warfarin reversal guidelinesObstetric haemorrhage: consider additional fibrinogen replacementSevere traumatic brain injury:permissive hypotension relatively contraindicatedavoid tranexamic acidOlder adults:hypotension and tachycardia may be late observationscarefully consider permissive hypotensionGastrointestinal bleeding:do not use high dose tranexamic acidSpecial clinical situations