A practical, evidence-based guide for front-line physicians on how to Treat the Bleed

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Patient outcomes are dependent on the quality of care provided by a high-performing interdisciplinary team including: physicians in emergency medicine, trauma, anesthesia, hematology/transfusion medicine, critical care, obstetrics; nurses; laboratorians in core laboratory and transfusion medicine; respiratory therapists; patient support workers; and porters.


  • The MHP team must have a leader
    • The plan should specify how the leader is designated
  • The MHP team should also ideally include other physicians/clinicians to assist with care, including nurses (one to chart and one to provide care), porter or runner, transfusion medicine technologist, core laboratory technologist, and respiratory therapist
  • MHP must clearly describe roles and responsibilities of team members:
    • The MHP leader orders initiation and termination of the MHP and leads resuscitations care
    • Nurses provide care (e.g., monitors, performs diagnostic phlebotomy, administers transfusions and medications)
    • Transfusion medicine lab medical laboratory technologist (MLT) performs compatibility testing and prepares and issues blood components
    • Lead lab and clinical communicators should be established to minimize duplicate orders and other confusion; check-ins should be done at specific time points and/or when significant events happen, such as a patient transfer
    • The core laboratory MLT performs and results tests; calls all critical results to the MHP bedside team
    • The porter or runner transports laboratory specimens and blood components
    • Central locating/switchboard connects relevant personnel
    • Other services (surgery, interventional radiology, endoscopy, etc.) may be consulted as necessary to control bleeding
  • Team members should receive training and optimally participate in drills/simulations
  • Team members should have access to reliable and mobile means of communication during MHP
  • Identify team members with easily identifiable signs and/or clothing (e.g., MHP leader, porter, charting nurse)
  • For centres where definitive bleeding control cannot be provided, arrange to move the patient ASAP to a tertiary care centre 


  1. Ali J, Rizolo S, Pavenski K. The Surgical Critical Care Handbook. Chapter 12: The Coagulopathic Trauma Patient and Massive Transfusion Protocol. World Scientific Publishing Co Pte Ltd. 2016.
  2. Callum JL, Yeh CH, Petrosoniak A, et al. A Regional Massive Hemorrhage Protocol Developed Through a Modified Delphi Technique. CMAJ Open. 2019;7(3):e546-561.
  3. Nunez TC, Young PP, Holcomb JB, et al. Creation, Implementation, and Maturation of a Massive Transfusion Protocol for the Exsanguinating Trauma Patient. J Trauma. 2010;68(6):1498-1505.
  4. Young PP, Cotton BA, Goodnough LT. Massive Transfusion Protocols for Patients With Substantial Hemorrhage. Transfus Med Rev. 2011;25(4):293-303.
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A practical, evidence-based guide for front-line physicians on how to treat acquired bleeding