Doctor

    Nurse/Lab

• Identify source

• Compression, tourniquet, packing

• Early surgery or angiography to stop bleeding

• In catastrophic hemorrhage, is bedside USG guided balloon occlusion or glue occlusion possible

• can use uncrossmatched o negative units in females less than 50 years and O- positive in males in extreme emergency

• Is cell salvage or autologous transfusion possible

• One lab technician to be at bedside immediately, All blood units will be delivered to ICU directly, not to lab.

• Do not ask for Donor. 

• CBC, COAGULATION PROFILE,FIBRINOGEN- Q12 HOURS

TEG- Based on clinicians advise

• Hb, Coagulation, ABG- every 30 minutes/1 hour/2 hours

• Take red tube *4 for cross matching, purple tube * 4 ( may need to be sent to different labs)

• Reports to be updated on quickest possible Turn Around Time. Set timers at bed side

Temperature < 35 degree celsius

External warming blankets with warmer, Temperature set at maximum, avoid unnecessary repeated exposure of patient

pH < 7.2, Base excess > -6

Discuss with senior clinician regarding need for early hemodialysis ,mechanical ventilation, Bicarbonate correction

Lactate > 4

Optimise other measures to improve oxygenation, perfusion, microcirculation

Ionized calcium (Target 4.5 on ABG, 9 on venous sample)

For every 4 units PRBC, give 2 grams of calcium gluconate

Platelets < 50000

1 unit SDP or 4 units RDP

PT / APTT > 1.5 times normal

INR <= 1.5 (INR not very helpful in cirrhosis)

FFP 15 ML/KG , usually 4 bags

Anticipate time delay for thawing

Consider 4 factor PCC-OCTAPLEX OR PROTHROM 250-2000 IU (D/w Hematologist)

Fibrinogen < 1·5 g/l (2 g/l for obstetric patients)

cryoprecipitate 3-4 grams (usually 8-10 bags)

Cryoprecipitate apheresis(usually 4-5 bags)

Allow time for thawing

Hb (based on clinical context) usual target >= 7

If giving very rapidly, use blood warming devices

Trauma <3 hours, obstetrics, high risk surgery(10 mg/kg load+1mg/kg/hr)

Tranexamic acid 1 gram over 10 minutes  and 1 grams over 8 hours infusion

Thromboprophylaxis- as soon as bleeding is definitively controlled

Start sequential compression device with thigh cuff early, start anticoagulation after concensus of all consultants involved

Source of bleeding

Methods to control bleeding

DOCTOR WILL Contact Immediately

Peripheral- compressible site

Direct compression, tourinquet(note time)

GI bleeding

Sengstaken blackmore, urgent Endoscopy

MGE CONSULTANT

Chest trauma

Thoracotomy

CTVS CONSULTANT

Aorto enteric fistula

? REBOA

CARDIOLOGIST/VASCULAR SURGEON

Aortic Aneurysm Rupture/Suspected Dissection

CARDIO/CTVS/VASCULAR/ANESTHESIA

Pelvic diastasis/ crush injury

REBOA

INTERVENTION RADIOLOGIST/CARDIO+ Anaesthetist

PPH

Uterine Artery Embolisation, Hysterectomy

INTERVENTIONAL RADIOLOGIST+ Anaesthetist

Post operative

Contact surgeon/Anesthetist

Neurogenic shock(may coexist)

Contact Neurosurgeon

STEP 1

Take blood sample red tubes-2

                              Violet tubes-2

Step 2

Fill blood requisition form

Inform lab incharge that bloody is needed urgently

Clearly tell products name and number of products needed.

Contact senior staff only and ask their name and document on  case sheet

Do not ask for donor until patients become stable.

Step 3

If PRBC arranged in Friends blood bank 

payment has to be made in our hospital IP billing counter.

If PRBC arranged from other blood banks

FFP,CRYO,SDP,RDP ARRANGED FROM ANY BLOOD BANK PAYMENT HAS TO BE MADE AT THE RESPECTIVE BLOOD BANK

Step 4

Blood bags brought from blood banks should be brought directly to the patients bedside and all documents verified at patient bedside.

Step 5

For each unit of blood ,document the name of blood bank in the brackets in the billing card.

Step 6

As soon as the patient is stable, ask relatives to arrange for donor before patient is transferred to ward.