ATLS primary survey (<C>ABCDE), damage-control resuscitation, tranexamic acid and activating the massive transfusion protocol.
At the bedside
Timed steps- 1
<C> Catastrophic haemorrhage
0 minDirect pressure, tourniquet for limb bleeding (note time), pelvic binder at the level of the greater trochanters for suspected pelvic fracture, haemostatic packing.
- 2
A with C-spine protection
0-2 minManual in-line stabilisation; jaw thrust; definitive airway if GCS ≤ 8, airway burns, or failing oxygenation. RSI with reduced induction doses in shock (e.g. ketamine 0.5-1 mg/kg).
- 3
B
2-4 minLook for tension pneumothorax, open chest wound, massive haemothorax, flail chest: needle/finger thoracostomy, three-sided dressing, chest drain.
- 4
C - identify bleeding
4-8 minTwo large-bore IVs (or IO), bloods incl. cross-match, ABG/lactate, fibrinogen. Sources: chest, abdomen, pelvis, long bones, external ('blood on the floor and four more'). eFAST.
- 5
Activate massive transfusion protocol
ASAPIf shock index > 1, ABC score ≥ 2, or ongoing bleeding with haemodynamic instability: activate MTP. Give PRBC:FFP:platelets 1:1:1; avoid > 1 L crystalloid. Give TXA 1 g within 3 h of injury.
- 6
Permissive hypotension until haemorrhage control
Target SBP 80-90 mmHg (MAP 50-60) in penetrating/blunt trauma without brain injury; MAP ≥ 80 mmHg if severe TBI. Vasopressors only if life-threatening hypotension despite fluids/blood.
- 7
Correct the lethal triad
Warm all fluids and the patient (core temp > 35 °C), keep ionised Ca > 1.1 mmol/L, fibrinogen > 1.5 g/L, platelets > 50 x10^9/L (> 100 if TBI or ongoing bleeding), avoid acidosis; use ROTEM/TEG if available.
- 8
Definitive control
Damage-control surgery or angioembolisation within 60 min of arrival for unstable patients. Stop MTP when bleeding controlled; switch to lab-guided transfusion.
Antifibrinolytic, within 3 h
Tranexamic acid
- Dose
- 1 g over 10 min, then 1 g over 8 h
- Preparation
- 1 g in 100 mL NS over 10 min; 1 g in 500 mL NS at 62.5 mL/h
Do not start beyond 3 h from injury.
MTP pack component
Packed red blood cells (PRBC)
- Dose
- 1:1:1 with FFP and platelets
- Target
- Hb 7-9 g/dL once bleeding controlled
- Worked example
- MTP pack 1 = 4-6 PRBC + 4-6 FFP + 1 apheresis platelet (or 4-6 random-donor units)
Fibrinogen replacement
Cryoprecipitate / fibrinogen concentrate
- Dose
- Cryo 1 unit/10 kg or fibrinogen concentrate 3-4 g if fibrinogen < 1.5 g/L
Prevent citrate-induced hypocalcaemia
Calcium chloride 10% / calcium gluconate 10%
- Dose
- Calcium gluconate 10% 30 mL (or CaCl 10% 10 mL) per 4 units of blood or as per ionised Ca
- Target
- Ionised Ca > 1.1 mmol/L
ABC score for predicting massive transfusion (1 point each, ≥ 2 = activate)
| Criterion | Point |
|---|---|
| Penetrating mechanism | 1 |
| SBP ≤ 90 mmHg in ED | 1 |
| HR ≥ 120 in ED | 1 |
| Positive FAST | 1 |
ATLS classes of haemorrhage (70 kg adult)
| Class | Blood loss | HR | BP | Action |
|---|---|---|---|---|
| I | < 15% (< 750 mL) | Normal | Normal | Observe, minimal fluid |
| II | 15-30% | Mild tachycardia | Normal, narrow pulse pressure | Crystalloid, possibly blood |
| III | 31-40% | Tachycardia > 120 | Decreased | Blood products, MTP likely |
| IV | > 40% | Marked tachycardia or brady | Severely low | MTP, immediate surgery |
Calculators for this topic
References
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Major trauma haemorrhage
Step 1 of ~5
Decision: Catastrophic external bleeding?
Based on Rossaint R, Afshari A, Bouillon B, et al; American College of Surgeons Committee on Trauma. Educational use; follow local protocol.
Pathophysiology
Trauma-induced coagulopathy starts within minutes of injury from tissue damage and shock (activated protein C, hyperfibrinolysis, fibrinogen depletion), and is worsened by dilution, hypothermia, acidosis and hypocalcaemia. Fibrinogen is the first factor to reach critically low levels.
Evidence
- CRASH-2 (20,211 patients): TXA reduced all-cause mortality (14.5% vs 16.0%) and bleeding deaths, greatest if given within 1 h; harm if after 3 h [CRASH-2 2010].
- PROPPR: 1:1:1 vs 1:1:2 did not change 24-h or 30-day mortality, but more patients achieved haemostasis and fewer died of exsanguination at 24 h with 1:1:1 [Holcomb 2015].
- European guideline 6th edition (2023): permissive hypotension, early fibrinogen, viscoelastic-guided therapy, calcium monitoring [Rossaint 2023].
Controversies
- Whole blood versus component therapy; prehospital plasma; fixed ratios versus early goal-directed viscoelastic therapy.
- REBOA use is limited and not recommended routinely.
🇮🇳 India notes
- Road traffic injuries are a leading cause of death in young Indians; most district hospitals lack platelets on demand. Plan transfers early and use fresh whole blood where component therapy is unavailable (per blood bank policy).
- TXA is cheap and widely available: give it in the ED or ambulance within 3 h.
- MTP should be written with the hospital blood bank (pack composition, who activates, runner, O-negative stock).
References
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Test yourself
Module quiz · score 70% to complete the module
Educational reference for trained clinicians. Check doses against your hospital protocol and the patient in front of you.