Metro North Hospital and Health Service

Royal Brisbane and Women’s Hospital

Procedure
Effective from: October 2022
Review date: October 2025

006971 Major Haemorrhage Protocol (MHP)

Purpose and intent

This procedure describes the correct processes to manage patients with critical bleeding who require or are
likely to require activation of the Major Haemorrhage Protocol (MHP) (Appendix 4). Major haemorrhage and
the development of coagulopathy can rapidly become life threatening and require a rapid transfusion of
allogeneic blood products.
Considering the high and potentially preventable mortality of massively bleeding patients, the use of the
MHP can facilitate appropriate decision making to support timely and appropriate interventions including
haemostatic products and surgical / interventional haemostatic management.
The MHP is used in diverse clinical scenarios in which critical bleeding occurs. The MHP aims to improve
clinical practice and patient outcomes.

Scope and target audience

This document applies to all Royal Brisbane and Women’s Hospital (RBWH) staff (permanent, temporary or
casual), students on placement within the RBWH and Australian Defence Force personnel working at
RBWH who are involved with the collection, storage and administration of blood and blood products, and
having completed all requisite training.
This procedure applies to adult patients, within all RBWH inpatient and outpatient units and wards.
Appendix 2 outlines the NBA blood component product information and dosage (Australia). The scope of
this document includes the following products supplied via Pathology Queensland (Blood Bank).
• Red cell concentrate (RBC)
• Platelets
• Fresh Frozen Plasma (FFP)
• Extended Life Plasma (ELP)
• Cryoprecipitate (Cryo)
• 20% Albumex®
• 4% Albumex®
• Prothrombinex®-VF
• Fibrinogen Concentrate (RiaSTAP)

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• Tranexamic Acid (TXA) (supplied by pharmacy).

Procedure
Alerts and special Considerations
MHP is a critical bleeding algorithm for an ADULT patient experiencing massive haemorrhage with
haemodynamic instability and anticipated ongoing blood product requirements. The management of critical
bleeding should focus on early recognition of blood loss, rapid volume control of the source of bleeding,
restoration of circulating blood volume, and coagulation management.
Massive transfusion is defined by the National Blood Authority (NBA) as:
• Adults – a transfusion of half of one blood volume in 4 hours, or more than one blood volume in 24
hours (adult blood volume is approximately 70mL/kg)
• Children – a transfusion of more than 40mL blood/kg (the normal blood volume of a child is
approximately 80mL/kg.)
For Paediatric MHP activation, refer to the Children Hospital Queensland (CHQ) Hospital and Health
Service procedure Blood and Blood Products: Massive Haemorrhage Protocol (MHP)

Activation and Deactivation of the MHP is the responsibility of the MHP Team Leader and must be clearly
communicated to RBWH Blood Bank (Pathology Queensland).
Prior to activation of an MHP, clinicians must take reasonable efforts to identify any documentation that
may inhibit the protocol from being activated and proceed accordingly. This documentation includes, but is
not limited to:
• Full or Limited Blood and Blood Products Consent form
• Refusal of Blood and Blood Products form
• Advance Health Directive (AHD)
• Patient Alerts
• Cultural Beliefs
If consent cannot be obtained (e.g., due to capacity concerns) and/ or where the patient requires urgent
treatment to save their life, the clinician should refer to the Metro North Hospital and Health Service (Metro
North) Blood and Blood Products, Management of 003336 procedure Section 2.3 Inability to give consent
for further guidance.

NOTE: If consent cannot be obtained, the medical officer MUST document in the patient’s medical record
the various things enabling blood product transfusions, as part of the MHP, to be carried out.

Hand Hygiene is the single most effective intervention to reduce the risk of Healthcare Associated
Infections. All staff who are involved in blood and blood transfusion processes, MHP or other, are expected
to comply with RBWH procedure 001947: Hand Hygiene and follow the National Infection Control
Guidelines, with consideration and adherence to personal protection and bodily fluid spills are a
requirement when handling blood and blood products.

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Emergency Red Cells – Volume Management
In the case of critical bleeding, transfusion of red cells may be all that is required to stabilise the patient. A
pack of Red Cells can be prepared for the patient in this case. Clinical assessment of the urgency of the red
blood cell transfusion will determine if the patient receives unmatched emergency Group O red cells
(MEDEVAC), group-specific, or crossmatched red blood cell unit. Group O unmatched red cells should be
used if blood is required in an emergency before the patient’s blood group testing has been performed. In
this scenario, Blood Bank must be notified of the patient’s sex and age (and name if available) to provide
the appropriate MEDEVAC units as described in figure 1. The un-crossmatched MEDEVAC blood
compatibility form must be completed. The original sent to Blood Bank and the copy to remain in the
patient’s medical record.

Figure 1. MEDEVAC blood supply

In all cases, a pre-transfusion sample of appropriately identified and labelled blood should be
obtained from the patient and sent to Blood Bank for blood group and antibody screen as soon as
possible. Once the blood group is completed group specific blood will be provided.

NOTE: Any unused ‘MEDEVAC’ units must be returned to Blood Bank as soon as possible

MHP Initiated – Managing Volume and Coagulopathy

Should an MHP be initiated, packs released from Blood Bank will be:

Major Haemorrhage Pack Two (2) RBC and Two (2) FFP
RBC within this pack may contain unmatched emergency
Group O red cells (MEDEVAC) or pre crossmatched red cells.

Major Haemorrhage Pack (ongoing) Two (2) RBC and One (1) FFP
Additional components as per algorithm/ROTEM

Appendix 4 outlines the processed to be followed for MHP at RBWH.

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Obstetric MHP Considerations
MHP activation for obstetric patients may require different stabilisation targets. Clinical consideration must
be given to targets of a higher FIBTEM A5 threshold (<12mm) for obstetric patients. Please note that in
addition to FIBTEM A5 threshold, fibrinogen level at term pregnancy should be 4-6g/L; <2g/L ~ A5<10mm
which leads to an increased risk of severe Postpartum Haemorrhage (PPH). Replace fibrinogen to target a
FIBTEM A5 value of 14mm or greater.
Also of note is that at term pregnancy, EXTEM A5 levels are higher (greater clot strength) compared to the
non-obstetric population and EXTEM CT levels are lower (faster clot formation) compared to the non-
obstetric population. This reflects the hypercoagulable picture seen with increasing gestation in pregnancy,
which is further exaggerated by changes that occur during established labour. It is important to keep this in
mind if these values are borderline and haemostasis has not been achieved clinically based on the non-
obstetric thresholds for transfusion of platelets or FFP, despite administration of uterotonics and other
measures being taken.
Please follow Queensland Health Initial response to primary postpartum haemorrhage (PPH) for further
management guidance and clinical considerations.

Theatre Red Blanket – No Identification

Please refer to the RBWH procedures 001733: Rapid transfer (Red Blanket) of the trauma patient from the
emergency and trauma centre to the operating room and 000745 Unknown patient, management of. This
Red Blanket procedure is a separate and some blood product amounts may differ.
On rare occasions, critically injured patients with ongoing life-threatening blood loss are transferred directly
to theatre without being registered in Hospital Based Corporate Information System (HBCIS). This will result
in a delay of at least 30 minutes before an appropriately labelled blood sample for crossmatching can be
provided. These patients may require large volumes of blood products in a short period of time, delay in the
provision of blood products is clinically unacceptable.
• Males of any age, and any female aged 50 or over, will be provided with group O Rh D Positive
blood.
• Females under the age of 50 will be supplied with 4 units of group O Rh D Negative blood
o If further blood is required and no sample has been received, group O Rh D Positive will be
supplied.

NOTE: Once the blood group is completed group specific blood will be provided. Any unused
‘MEDEVAC’ units must be returned to Blood Bank as soon as possible

Activation
Evaluation and assessment of the critically bleeding patient should be undertaken without delay and include
patient history, vital signs (at a minimum; heart rate, blood pressure, temperature, respiratory rate, and
oxygen (O2) saturation), peripheral perfusion, mental status, urine output, haemoglobin and haematocrit,
coagulation status and acid base status. Blood samples (Appendix 3), including electrolyte and liver
function tests, must be sent to the Blood Bank via a runner at the activation of the MHP.
Activation of the MHP in critically bleeding patients should be undertaken as early as possible by the MHP
Team Leader. Early activation is essential and should be considered for any of the following:
• Actual or anticipated requirement for transfusing ≥ four (4) units of red blood cells in ≤ four (4) hours
• Haemodynamic instability
• Severe thoracic, abdominal, pelvic, or multiple long bone trauma

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• Major obstetric, gastrointestinal, or surgical bleeding
• Ongoing bleeding (≥ 150mL/min)
• Clinical or laboratory signs of coagulopathy

ROTEM

NOTE: ROTEM or NON-ROTEM guided pathways must be clearly communicated to the Blood Bank
as early as clinically possible.

If a ROTEM blood test is being sent to Blood Bank, this will trigger a ROTEM guided pathway, unless the
MHP Team Leader notifies the Blood Bank with a verbal or written intention to NOT follow the ROTEM
guided pathway. If NOT following the ROTEM guided pathway, the MHP Team Leader must also request
products required.
• Coagulation blood tube (blue top filled to the line) and a Pathology Queensland request form is
required for ROTEM test – written intention to NOT follow ROTEM path can be made using
clinical notes.
• ROTEM MUST be hand -delivered to Blood Bank (level 4, Ned Hanlon building).

NOTE: To remotely view ‘live’ ROTEM results, ROTEM Secure Viewer must be installed on a local
computer/ device
The TEM/TEG app is available to assist in utilisation of the ROTEM guided pathway, including Obstetric
MHP guidance – use QR code in Appendix 4

Permissive Hypotension
Permissive Hypotension (toleration of systolic blood pressure of 80-100mm Hg) and minimal volume
resuscitation are preferred over aggressive volume resuscitation while active bleeding is controlled.

NOTE: Aggressive volume resuscitation (with crystalloid solution) can lead to serious complications such
as:
• Oedema, compartment syndrome and acute lung injury
• Exacerbation of anaemia, thrombocytopenia and coagulopathy related to haemodilution
• Exacerbation of bleeding due to clot disruption

Tranexamic Acid (TXA)

TXA should be given as early as possible (within three (3) hours of injury). In trauma, it is empirically
administered as a 1g bolus over 10 minutes followed by 1g infusion over eight (8) hours or another bolus
(as clinically indicated). TXA is only available from Pharmacy.

Fibrinogen concentrate (RiaSTAP)

RiaSTAP can be obtained from Blood Bank. It can be used if Fibrinogen < 1.5g/L or Fibtem < 8mm (<3.0g/L
or <10mm for obstetrics). It is used in time critical situations at a dose of 4g. A further dose can be given if
repeated parameters are below targets and time remains critical (maximum of 8g).

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Calcium gluconate
Ionised calcium plays an essential role in formation and stabilisation of fibrin polymerisation sites, platelet-
related function and as a coagulation co-factor. Acute hypocalcaemia is common in massive transfusion
and associated with increased mortality. Hypocalcaemia can be worsened by citrate chelation due to
transfusion as citrate is a preservative and anticoagulant in packed RBC and FFP. Monitor ionised calcium
and correct hypocalcaemia by giving calcium chloride 1g/10ml or calcium gluconate 1g/10ml. Consider
using calcium gluconate 1g for every two (2) units if ionised calcium is not available.

Clinical parameters/ targets

Parameters and targets should be measured and reviewed early and frequently in patients receiving
massive transfusion. Hypothermia, metabolic acidosis, thrombocytopenia, and coagulopathy may be
independently associated with increased mortality. Values trending toward “normal” indicate a response to
treatment (Appendix 3).

Blood warmers
Blood warmers are recommended when transfusing fresh RBC during the MHP

Special Situations
The below should be considered at the activation of the MHP to ensure appropriate treatment is received:

Warfarin Administer:
• Vitamin K 5mg – 10mg Intravenously (IV)
• Prothrombinex 25 – 50 IU/kg

Dabigatran / Rivaroxaban / Discuss with Haematologist

Apixaban (DOACs)

Antiplatelets drugs Additional platelets

Obstetric Haemorrhage Target fibrinogen >3.0g/L

Head Injury Target platelets >100 x 109/L

Target SBP >100mmHg

Deactivation
Deactivation is the responsibility of the MHP Team Leader and must be communicated to the Blood Bank
immediately.
All blood products not currently being administered MUST remain within the designated transportation
shipper in the correct packing configuration to ensure blood products are stored at the correct temperature
and unused blood products are required to be returned to the Blood Bank as soon as possible as per the
Blood and Blood Products, Management of 003336 (MNHHS) procedure (Section 6: Storage and
Transportation).

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Roles and Responsibilities

Team Leader
A team leader must be identified to lead the activation, management, and deactivation of the MHP. This
should be a Consultant, Senior Registrar or most Senior Clinician present. The team leader is
responsible for the following, either directly or indirectly:
• Activation and coordination of the MHP
o The Blood Bank MUST be contacted and notified of the MHP, including identification of the
MHP Team Leader

NOTE: ROTEM or NON-ROTEM guided pathways must be clearly communicated to the Blood Bank as
early as clinically possible.

• Blood product requests and other blood product requirements if differing from the MHP Pathway
(appendix 4)
o Cryoprecipitate and FFP require at least 20 minutes to thaw – this should be noted when
requesting cryoprecipitate or FFP (appendix 4).

NOTE: The order for cryoprecipitate will be for whole blood cryoprecipitate. One apheresis
cryoprecipitate unit is equivalent to two (2) whole blood cryoprecipitate.

o Initial blood products (packs or individual bags) must be communicated verbally and
requested via Pathology Queensland – all blood products must be prescribed and recorded.

NOTE: If blood products are requested that differ from the MHP packs/pathway, this must be clearly
communicated to the Blood Bank, including ongoing blood product requirements.

• Appropriate management of investigation and interventions within the team

o Including blood samples every 30-60 minutes (or as clinically indicated) of the MHP to
assess ongoing requirements.
o Recommended blood test requests below:
 Cross match (CXM)
 Full Blood Count (FBC)
 Coagulation studies (COAG)
 Ionised Calcium (iCa)
 Arterial Blood Gas (ABG) or Venous Blood Gas (VBG)
 Electrolyte and Liver Function Tests (eLFT)
• Continually assess the ongoing need for transfusion
• Identifying when targets are met:
o Temperature ≥36°C
o iCa ≥1mmol/L
o Platelets ≥70 x 109/L
o Fibrinogen ≥2g/L or ≥3g/L (Obstetrics)
o pH ≥7.2
• Deactivation of the MHP

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o Blood Bank MUST be notified by clearly communicating the cessation of the MHP as soon
as clinically relevant to avoid blood product wastage.
o Activation and deactivation are clinical decisions based on the patient’s clinical conditions,
response, and outcomes.

Designated Blood Bank Contact

The designated Blood Bank contact will be responsible for all communication received within Blood Bank
and will notify the MHP Team Leader on status of products. The Blood Bank contact will:
• Appropriately communicate with other Blood Bank staff regarding product requests, status, and
collection/delivery of products.
• Notifying the MHP team leader of product status collection/delivery of products.
• Ensure correct packing configuration of esky/shipper to maintain cold chain of blood products.
The below roles and responsibilities align with the Blood and Blood Products, Management of 003336
(MNHHS) procedure. As per this procedure, all requisite training is required when handling blood and blood
products as part of the MHP team.

Medical Officers and Endorsed Nurse Practitioners

Within practice scope, are responsible for:
• Prescribing blood and blood products
• Maintain cold chain compliance of blood products
• Ensuring adequate documentation of blood transfusion request in the patient health care record,
including documentation of consent.
• Reporting transfusion adverse events to Blood Bank and completing a RiskMan

Registered Nurses/ Midwives/ ADF Registered Medical Officers

Can perform the following actions and are responsible for:
• Obtaining/arranging venepuncture for the pre-transfusion specimens for compatibility testing.
• Collection of blood products from the Blood Bank.
• Maintain cold chain compliance of blood products.
• Provision of patient information brochures relating to blood transfusion.
• Confirming valid informed consent for blood transfusion is appropriately documented by a Medical
Officer/endorsed Nurse Practitioner prior to commencing transfusions.
• Explanation to the patient of the signs and symptoms of possible blood transfusion reactions in the
event of this occurrence.
• Safely carrying out the procedure for the administration of blood products, including:
o Checking of blood and blood products as per Blood and Blood Products, Management of
003336 (MNHHS) procedure Section 7: Administration.
• Monitoring patients during transfusion and carrying out the appropriate actions in the event of
adverse events.
• Reporting of transfusion reactions or other incidents related to the transfusion to the Medical
Officers, to the Blood Bank and RiskMan.

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Enrolled Nurses and Student Nurses
As per Blood and Blood Products, Management of 003336 (MNHHS) procedure

Unlicensed Healthcare Workers/ Operational Support Officer (AIN/ Ward person)

• Can collect blood and blood products from Blood Bank or blood storage refrigerator provided there
is a record of education and local orientation has been recorded by responsible Manager
• Are not permitted to supervise a Student Medical Officer/Nurse/Midwife directly or indirectly in the
checking of blood products

Anaesthetic Healthcare Practitioners (AHP)

• Check and connect blood products under the direct supervision of an anaesthetist or medical officer
(in Theatre and Intensive Care Unit) provided they have completed requisite training (BloodSafe
eLearning).
• Are not permitted to supervise a Student Medical Officer/ Nurse/ Midwife directly or indirectly in the
checking of blood products.
• May supervise the checking of a product with a Student Anaesthetic Technician providing the
second checker is a Medical Officer/Registered Nurse/Midwife.

Perfusionists
• Administer of blood and blood products.
• Monitor patients during transfusion and carrying out the appropriate actions in the event of adverse
events.
• Report transfusion reactions or other incidents related to the transfusion to the treating Medical
Officer, to the Blood Bank, and via the RiskMan incident reporting system.

NOTE: Refer to Blood and Blood Products, Management of 003336 (MNHHS) procedure and Pathology
Queensland requirements for cold chain compliance, blood product storage and transportation,
administration, and monitoring process.

Partnering with consumers

Patients and family members, or if applicable appropriate substitute decision-maker, are to be encouraged
and given the opportunity to ask questions, clarify information and identify goals of care during
communication processes, including being advised regarding their right to privacy and confidentiality. Staff
are responsible for providing information in a way that is understandable and that meets patient’s needs
and are to use perception checking techniques to ensure patient and family’s understanding of discussions.
A translator may be booked to promote consumers’ cultural right to communicate in a language of their
choosing (per sections 27 and 28 of the Human Rights Act 2019 (Qld) (‘Human Rights Act’) on the Metro
North Hospital Intranet Booking an interpreter page.
Relevant support services include:
• Auslan and Real Time Captioner (RTC) Interpreter requests can be made by contacting 3624 1257;
for emergency requests outside business hours Deaf Services Queensland can be contacted on
0455 068 500. See the website here for more information – please note that bookings can be made
in advance online.
• Chaplaincy Services can be accessed for those seeking spiritual or emotional support – please
contact 3646 8402, 3646 8405 or 3646 7988 between 8am and 3:30pm Monday to Friday, or
Switchboard on extension 9 for urgent or out of hours requests. See the website here for more
information.

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Aboriginal and Torres Strait Islander considerations

RBWH is committed to protect the public from harm and to improve the quality of health service provision.
The National Safety and Quality Health Service Standards identify six actions specific to the provision of
care for Aboriginal and Torres Strait Islander peoples. The attendance to these actions provides assurance
that service provision is equitable, and that patient needs drive the level and range of care that can be
accessed. See the Australian Commission on Safety and Quality in Health Care for further information:
https://www.safetyandquality.gov.au/topic/user-guide-aboriginal-and-torres-strait-islander-health
RBWH is committed to reducing the health disparities between Aboriginal and Torres Strait Islander
peoples and non-Indigenous Australians, and the removal of treatment inequities in the health system. Our
care delivery is shaped by the Metro North Better Together Plan and RBWH Closing the Gap Plan
commitments.
The RBWH respects, protects and promotes the cultural rights of Aboriginal and Torres Strait Islander
peoples. Please advise Aboriginal and Torres Strait Islander patients, their families and/or substitute
decision-makers of the availability of Indigenous Hospital Liaison Officers (IHLO) in recognition of their
cultural and language rights under Section 28 of the Human Rights Act. This service can be reached by
contacting 3646 4154 during office hours, and 3647 4183 or 0428 861 888 after hours. See the website for
more information: https://qheps.health.qld.gov.au/rbwh/allied-health/atsi-liason.

Legislation and other authority

Human Rights Act 2019 (Qld)
Powers of Attorney Act 1998 (Qld)
Guardianship and Administration Act 2000 (Qld)
National Blood Authority Act, 2003
Transplantation and Anatomy Act 1979
Australian Standards AS3864.2-2012:
Medical refrigeration equipment- for the storage of blood and blood products
National Safety and Quality Health Service (NSQHS)
• Standard 1 Clinical Governance
• Standard 2 Partnering with Consumers
• Standard 4 Medication Safety
• Standard 7 Blood Management
• Standard 8 Recognising and Responding to Acute Deterioration
National Pathology Accreditation Advisory Council (NPAAC)
National Association of Testing Authorities Australia (NATA)
Therapeutic Goods Administration (TGA)
Australian New Zealand Society of Blood Transfusions (ANZSBT)
Pre-Transfusion Testing Guidelines (2007)
Administration of Blood Products (2011)
Prevention of Transfusion-Associated Graft-Versus-Host Disease (2011)
National Blood Authority (NBA) Patient Blood Management Guidelines

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Pathology Queensland QIS procedure manual
Transportation of Blood Products
Australian Red Cross Blood Service (ARCBS)
Queensland Health Guide to Informed Decision-making in Health Care (2017)

All staff must respect, protect and promote human rights in their daily practice. Properly
consider human rights prior to making any decisions, or taking actions, to ensure your
decisions and actions are compatible with upholding the human rights of all people, including
staff, patients, and their families*.
A failure to adequately do so may be deemed unlawful under section 58 of the Human Rights Act.
Human Rights considerations relevant to this procedure include:
• Cultural rights – generally (section 27) and specific cultural rights of Aboriginal and Torres
Strait Islander peoples (section 28)
• Freedom of expression (section 21):
o right to hold an opinion without interference.
o right to seek, receive and impart information
• Freedom of movement (S 19)
• Freedom of thought, conscience, religion and belief (section 20)
• Humane treatment when deprived of liberty (section 30)
• Right to privacy and reputation (section 25)
• Protection from torture and cruel, inhuman or degrading treatment (section 17)
o subsection (b), treated in a cruel, inhuman or degrading way
o subsection (c), the right to protection from being subject to medical treatment without
full, free and informed consent.
• Protection of families and children (section 26)
• Recognition and equality before the law (section 15)
• Right to health services (section 37)
• Right to liberty and security of person (section 29)
o Physical and mental safety of persons
• Right to life and not to be arbitrarily deprived of life (section 16)
*Section 4(b) Human Rights Act.

References
National Blood Authority
• Patient Blood Management Guidelines Module 1: Critical Bleeding Massive Transfusion
• Quick Reference Guide: Patient Blood Management Guidelines Module 1: Critical Bleeding Massive
Transfusion
Australian Commission on Safety and Quality in Healthcare – NSQHS Standards: 7 Blood Management
The Prince Charles (MNHHS) Massive Haemorrhage Protocol (MHP) – 004589 procedure

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Redcliffe Hospital Massive Transfusion Protocol (MHP) – 004554 procedure
Children’s Hospital Queensland Blood and Blood Products: Massive Haemorrhage Protocol (MHP)
Blood and Blood Products, Management of 003336 (MNHHS) procedure
Pathology Queensland: Storage and Transportation
Flowchart: Initial response to PPH (health.qld.gov.au)
Stanworth SJ, Dowling K, Curry N, Doughty H, Hunt BJ, Fraser L, et al., on behalf of The Transfusion Task
Force of the British Society for Haematology. A guideline for the haematological management of major
haemorrhage: A British Society for Haematology Guideline. Br J Haematol. 2022;00:1–14 . https://doi.org
/10.1111/ bjh.18275
Rowell SE, Meier EN, McKnight B, et al. Effect of Out-of-Hospital Tranexamic Acid vs Placebo on 6-
Month Functional Neurologic Outcomes in Patients with Moderate or Severe Traumatic Brain Injury. JAMA.
2020 Sep 8;324(10):961-974. doi: 10.1001/jama.2020.8958.

Related documents
MNHHS Blood Management Policy
MNHHS Procedure: Blood and blood products, management of
MNHHS Emergency Blood Management Plan
National Blood Authority
Patient Blood Management Guidelines (Module 1): Critical Bleeding/ Massive Transfusion
National Pathology Accreditation Advisory Council (NPAAC)
National Association of Testing Authorities Australia (NATA)
Therapeutic Goods Administration (TGA)
Australian New Zealand Society of Blood Transfusions (ANZSBT)
• Pre-Transfusion Testing Guidelines (2007)
• Administration of Blood Products (2011)
• Prevention of Transfusion-Associated Graft-Versus-Host Disease (2011)
National Blood Authority (NBA) Patient Blood Management Guidelines
Pathology Queensland QIS procedure manual
• Transportation of Blood Products
Australian Red Cross LifeBlood (ARCL)
Queensland Health Guide to Informed Decision-making in Health Care (2017)
Transplantation and Anatomy Act 1979 – Section 20

Supporting principles

Prior to procedures -
• Always confirm correct patient identity as per Metro North procedure 003862: Patient Identification
and Procedure Matching. As per this procedure, verbal identification should, unless not reasonably
practical, be undertaken in an area where privacy and confidentiality of the patient can be
maintained. A failure to protect a patient’s privacy from unlawful or arbitrary interference may be a
breach of section 25(a) of the Human Rights Act and our/your human right obligations under
section 58 of the Human Rights Act.

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• Always explain the procedure to the patient and their family/(ies) or if applicable, appropriate
substitute decision-maker 1, provide an adequate opportunity for them to ask any clarifying questions
and ensure consent is obtained in accordance with 001744: Patient Consent. A failure to obtain
proper informed consent can breach the human rights of a patient as per section 17(c) of the Human
Rights Act and our/your human right obligations under section 58 of the Human Rights Act.
• Hand hygiene should be performed when undertaking patient procedures in accordance with
001947: Hand Hygiene
• All actions and procedures undertaken are to be documented in accordance with 001072:
Documentation in the Patient Record
• Clinical Handover including critical information is to be undertaken in accordance with Metro North
Policy – Communicating for Safety.
• Clinical Incidents are to be managed in accordance with Metro North 002044: Clinical Incident
Management
• Always undertake aseptic technique during clinical procedures, in accordance with Metro North
006517 Aseptic Technique

Appendix 1 – Definition of terms

Term Definition

Defined as a major haemorrhage that is life threatening and likely to result in the
Critical Bleeding
need for massive transfusion
Adults – a transfusion of half of one blood volume in 4 hours, or more than one
blood volume in 24 hours (adult blood volume is approximately 70mL/kg)
Massive Transfusion
Children – a transfusion of more than 40mL blood /kg (blood volume in children
older than neonates is approximately 80mL/kg

Permissive A strategy in which systolic blood pressure of 80-100mmHg are tolerated whilst
hypotension bleeding is controlled

MEDEVAC Unmatched emergency Group O red cells issued based on age and sex
An AHD is a formalised version of an advance care plan. It outlines consumers
preferences for future care along with outlining beliefs, values, and goals. An AHD
can identify a formally appointed substitute decision-maker of the consumer when
Advance Health
Directive (AHD) they can no longer make decisions by themselves.
Advance care directives differ between states and territories. Some state and
territory governments have specific forms that you can use.

Red Blanket – No Critically ill patient transferred to theatre who has not been registered on HBCIS
Identification and requires massive transfusion

1 Powers of Attorney Act 1998 (Qld); Guardianship and Administration Act 2000 (Qld)
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Appendix 2 – Product Information (NBA PBM Guidelines) Plasma

and Platelets

Typical Adult Number of bags

Component Content and Characteristics Volume/ bag
Dose (~70kg) to provide

• Plasma recovered from a

whole blood donation or
Fresh Frozen apheresis collection 250 – 334mL 10 – 15mL/ kg 3-4
Plasma (FFP)
• Contains all coagulation
factors

• A pool of platelets derived

Platelets from the buffy coat of four
whole blood donations ≥160mL 1 bag 1
(pooled)
• Leucodepleted

• A suspension of platelets
Platelets prepared from a single
apheresis donor 100 – 400mL 1 bag 1
(apheresis)
• Leucodepleted

• Prepared from a single

donated whole blood unit
• Contains an average of >0.35
g/bag
Cryoprecipitate 30 – 40mL 3-4g fibrinogen 8 – 10
• Contains high levels of
fibrinogen, factor VIII, von
Willebrand factor, factor XIII,
fibronectin

• Prepared from FFP obtained

from a plasmapheresis donor
Cryoprecipitate • Contains an average of >0.8 60 mL
3-4g fibrinogen 4–5
(apheresis) g/bag (±10%)
• Equivalent to 2 whole blood
cryoprecipitate packs

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Appendix 3 – Summary of Key NBA Recommendations

• Take samples at earliest
opportunity as results may be
• FBC, PT, APTT, Fibrinogen (Clauss method): affected by colloid infusion
• Blood Bank sample for type and screen, biochemical • Ensure correct patient
Laboratory profile, blood gases and pulse oximetry. identification
investigations
• Ensure correct sample identification • Send accompanying Pathology
Queensland form
• Repeat tests after blood component infusion
• May need to give components
before results are available

• Use group MEDEVAC products in extreme emergency

until ABO and Rh D groups known
• Transfusion laboratory will
• Use ABO group specific when blood group known complete cross match after issue
Maintain Hb >80
g/L • Use fully compatible blood if time permitting • Further compatibility test not
required after 1 blood volume
• Use blood warmer and/or rapid infusion device
replacement (about 10 units)
(hypothermia defined as core body temp <35̊C is
associated with acidosis, hypotension, and coagulopathy)

Maintain platelet • Allows margin of safety to ensure

count • Allow for delivery time from blood centre. Anticipate
platelet count > 75 × 109/L
platelet count <50 × 109/L after 2 × blood volume
> 75 × 109/L replacement • Keep platelet count >100 × 109 /L
>100 × 109 /L for if multiple or CNS trauma or if
head injury platelet function abnormal

• INR.>1.5 & APTT >60 correlates

• Give FFP 10-15ml/kg, further requirement guided by with increased microvascular
coagulation tests bleeding

Maintain INR • Anticipate need for FFP after 1-1.5 × blood volume • Keep ionised Ca2+ >
replacement
<1.5 & APTT • 1.00mmol/L
• Allow for 20-30 minutes thawing time
<60 • The effect of hypothermia on
• Use blood warmer and/or rapid infusion device coagulation factor activity may be
(hypothermia defined as core body temp <35̊C is underestimated because
associated with acidosis, hypotension, and coagulopathy) INR/APPT assays are performed
at 37̊C

Maintain
• Give cryoprecipitate (10 units of Cryoprecipitate for and
Fibrinogen
adult) • Fibrinogen < 0.5 strongly
> 1.5g/L associated with microvascular
• Allow 30 minutes thawing time
bleeding
(> 2.5g/L if
pregnant)

RiaSTAP NBA has not noted RiaSTAP as part of the key recommendations

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Appendix 4 – RBWH Major Haemorrhage Protocol (MHP) – Adult

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Document history
Author Clinical Nurse Consultant (CNC) Blood Management RBWH

Custodian RBWH Blood Management Committee (BMC)

Compliance As per RBWH Standard 7. Blood Management Audit Schedule and Key
evaluation and Performance Indicators. The below results and outcomes are discussed at
audit quarterly RBWH BMC:
• Appropriate Blood Use Monitoring
• Wastage Rates
• Clinical Weekly Audit
o Audit results reviewed at RBWH BMC Committee and are
reported via Service Line Quarterly Reports to the Safety and
Quality Committee, with actions agreed as indicated
• Adverse clinical events and blood management incidents are documented
in RiskMan. They are reviewed, and action progressed to the relevant
stakeholders as required
o Escalation to Safety & Quality Committee as deemed necessary
by the BMC
• Requisite Training Compliance will be monitored via TMS by the BMC
and reported quarterly
o Internal education sessions available at the request of streams
and wards and will be delivered by the Blood Management CNC
and records maintained on file

Consequence Major/Likely/High (20)/Tolerable

rating

Replaces New document.

Document/s

Changes to Human Rights Compatibility Assessment completed 03/08/2022

practice from
previous version

Education and Internal education sessions available at the request of streams and wards and
training to support will be delivered by the Blood Management CNC.
implementation
Bloodsafe eLearning Clinical Transfusion Practice module requisite training
monitoring for all staff.

Consultation Key stakeholders

• Blood Management CNC RBWH
• Blood Management Committee Chairperson RBWH
• Executive Director Cancer Care Services RBWH
• Emergency & Trauma Centre Staff Specialists RBWH

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• Intensive Care Consultant RBWH
• Director Anaesthesiology RBWH
• Anaesthesiology Staff Specialist RBWH
• Anaesthesiology & Perioperative Staff Specialist RBWH
• Haematology Staff Specialist RBWH
• Laboratory Haematology Staff Specialist RBWH
• Clinical Director Gynaecology Services RBWH
• Obstetric Staff Specialist RBWH
• Critical Care Services CNC
• Women’s and Newborn Services Safety and Quality CMNC
• Pathology Queensland Supervising Scientist
• MNHHS Patient Safety & Quality CNC
Broad Consultation
• Blood Management Committee endorsed August 2022
• Pathology Queensland Blood Bank RBWH
• Haematology & Bone Marrow Transplant Medical Team
• Executive Medical Directors, Service Lines
• Medical Directors, Service Lines
• Nursing and Midwifery Services
• Safety & Quality Officers
• Workforce Development and Education Unit
• Safety and Implementation Service
• Integrated Risk Manager
• Legal Metro North
• Medicines Committee endorsed on 13/09/2022.

Marketing Strategy RBWH Intranet PPP site “What’s New Site” and local dissemination

Key words 006971, Massive transfusion, major haemorrhage, critical bleeding, MEDEVAC,
MHP, blood, red blood cells, RBC, fresh frozen plasma, FFP, red blanket, blood,
ROTEM, coagulopathy, volume, NSQHS, Standard 7, S7, obstetric, emergency,
platelets, extended life plasma, ELP, cryoprecipitate, cryo, albumex, albumin,
prothrombinex, fibrinogen concentre, RiaSTAP, tranexamic acid, TXA.

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Custodian Signature Date

Blood Management Committee (Co -Chairperson), Royal Brisbane and Women’s Hospital

AUTHORISATION

Authorising Officer Signature Date

Director Medical Services, Royal Brisbane and Women’s Hospital

The electronic signed version is retained by the RBWH Safety and Implementation Service (SIS)

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