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

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Test hourly

The patient should have blood testing upon initiation of the MHP and then repeated at least hourly thereafter.

  • Laboratory testing can help identify patients receiving oral anticoagulant therapy and in need of reversal, assess quality of resuscitation, and guide blood component administration
  • Blood component therapy is administered at a 2:1 ratio (RBC to plasma) and then switched to goal-directed as soon as practical
  • Recommended tests include hemoglobin and platelet count, coagulation tests, and markers of organ injury and/or shock
  • Occasionally, blood testing may need to be done more frequently, based on clinical situation


  • Recommended blood test bundle includes:
    • ABO blood group, antibody screen, and ABO verification
    • Complete Blood Count (CBC), International Normalized Ratio (INR), activated Partial Thromboplastin Time (aPTT), fibrinogen, Arterial Blood Gas (ABG), ionized calcium, lactate, and electrolytes
      • Note: aPTT does not need to be repeated as long as first PTT is concordant with the baseline INR
    • If available, rotational thromboelastometry (ROTEM) or thromboelastography (TEG) may also be useful
  • Biochemical tests (e.g., potassium, calcium, and pH) may indicate potential complications from massive transfusion or inadequate resuscitation of the patient in hemorrhagic shock
  • Lactate measurements are predictive of mortality, although the role of serial measurements in improving patient outcomes has not been confirmed in clinical trials
  • Laboratory should call all critical results to the bedside team

Having access to the most up-to-date laboratory results allows for more effective resuscitation and may improve patient outcomes.

Ensure correct blood work is drawn at the beginning of MHP and repeated hourly.



  1. Bawazeer M, Ahmed N, Izadi H, et al. Compliance With a Massive Transfusion Protocol (MTP) Impacts Patient Outcome. Injury. 2015;46(1):21-28.
  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. Chandler WL, Ferrell C, Trimble S, et al. Development of a Rapid Emergency Hemorrhage Panel. Transfusion. 2010;50(12):2547-2552.
  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