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

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Terminate the code

Once bleeding is under control, terminate MHP.


  • Termination process and criteria must be clear to all team members
    • Terminate protocol when hemostasis is achieved and patient is stabilized or when patient dies
    • Call transfusion medicine laboratory to terminate protocol
  • Transfer care to the most appropriate team
    • Complete charting and reconcile transfused components
    • Update patient’s family
    • Consider transporting patient to a higher acuity hospital if more intensive care is needed and/or definitive interventions are needed
  • Return all blood components and blood containers/coolers remaining at bedside to transfusion medicine laboratory
    • Blood components can be transfused up to 4 hours post-issue
    • Blood components issued and outside of a validated temperature controlled environment (i.e., blood cooler or fridge) for more than 1 hour (not cumulative) cannot return to inventory and will be discarded by the transfusion medicine lab; to ensure no wastage, portering should be contacted as soon as MHP stands down
  • Team debriefing
    • What went well and what can be done better next time
    • Improves compassion fatigue and promotes resiliency, enables quality improvement
  • Multidisciplinary review for quality assurance
    • Mortality and morbidity rounds – focusing on facts rather than “blame”
    • Others: trauma care committee, transfusion committee

Quality metrics should be tracked over all activations of the MHP.

  • Based on audits of blood component utilization:
    • Common errors made:
      • Starting right away with RBCs, FP, platelets in bleeding patients on the ward (for example, most GI bleeds can start with 2-4 RBCs and do not require other components)
      • Ordering 4 doses of platelets when clinicians are thinking of 4 units of platelets; correct terminology is “1 adult dose” = 4 units of whole blood–derived platelets = 1 unit of apheresis platelets
      • Not moving towards goal-directed therapy and sticking to ratio-based therapy, or focusing only on giving large amounts of RBCs
      • Not checking and/or replacing fibrinogen
      • Not getting a group and screen and overusing group O RBCs and AB plasma
        • Getting a group and screen post-transfusion of group O RBCs is still useful for determining the patient’s blood group

Example Set of Quality Metrics

  • Proportion of patients receiving tranexamic acid within 1 h of protocol activation
  • Proportion of patients in whom RBC transfusion is initiated within 15 min of protocol activation
  • Proportion of patients (of those requiring transfer for definitive care) with initiation of call for transfer within 60 min of protocol activation
  • Proportion of patients achieving temperature ≥36°C at termination of the protocol
  • Proportion of patients with hemoglobin levels maintained between 60 and 110 g/L during protocol activation, excluding certain pediatric populations (e.g., neonates) that may require higher hemoglobin values
  • Proportion of patients transitioned to group-specific RBCs and plasma within 90 min of arrival/onset of hemorrhage
  • Proportion of patients with appropriate activation (≥6 RBC units in first 24 h, >40 mL/kg per 24 h of RBCs in pediatric patients) or before this level in patients dying due to hemorrhage within 24 h
  • Proportion of patients without any blood component wastage (including plasma that is thawed and not used within the 5-day limit on another patient)

Regular simulations increases team building and non-technical skills in trauma

  • Can range from a table-top exercise to high fidelity in situ simulations
  • Consider having video recordings of lab and clinical areas to raise awareness of roles within the MHP


  1. Barleycorn D, Lee GA. How Effective Is Trauma Simulation as an Educational Process for Healthcare Providers Within the Trauma Networks? A Systematic Review. Int Emerg Nurse. 2018;40:37-45.
  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. Rao S, Martin F. Guideline for Management of Massive Blood Loss in Trauma. Update in Anaesthesia. 2012;28(1):125-129.
  4. Schmidt M, Haglund K. Debrief in Emergency Departments to Improve Compassion Fatigue and Promote Resiliency. J Trauma Nurse. 2017;24(5):317-322.
  5. Spahn DR, Bouillon B, Cerny V, et al. The European Guideline on Management of Major Bleeding and Coagulopathy Following Trauma: Fifth Edition. Crit Care. 2019;23(1):98.
  6. Yazer MH, Spinella PC, Doyle L, et al. Transfusion of Uncrossmatched Group O Erythrocyte-containing Products Does Not Interfere With Most ABO Typings. Anesthesiology. 2020;132(3):525-534.
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A practical, evidence-based guide for front-line physicians on how to treat acquired bleeding