EMS calls with report: 64-year-old male patient with a crush injury to his chest after being run over by a tractor. Patient is alert, has absent breath sounds on L side of his chest, and had L chest decompression on scene. They are 20 minutes out.
Crush injury to chest with hemodynamic instability (BP 88/62, HR 125) and absent left breath sounds = high probability of traumatic hemothorax/massive chest bleeding.
- Mechanism: tractor crush — high-energy blunt trauma to thorax
- Absent breath sounds L side + chest decompression on scene = pneumothorax/hemothorax
- Shock Index (HR/SBP): 125/88 = 1.42 — significantly elevated, consistent with hemorrhagic shock
- This patient will likely need chest tube insertion and MTP on or shortly after arrival
- Prioritize ED hemorrhage workflow: chest tube setup, MTP readiness, Blood Bank communication, and transfer planning
ED-specific: The charge RN can notify Blood Bank of an incoming patient who may require MTP. This gives Blood Bank a heads-up to begin preparing.
- This is a notification only — Blood Bank cannot release products until activation is confirmed after patient arrival
- Activation requires provider assessment and decision after arrival
- Call Blood Bank at x6544 with: "Incoming trauma, possible MTP. ETA 20 minutes."
- Blood warmer and Level 1 rapid infuser plugged in/warming and ready
- Large-bore IV supplies (backup access if EMS lines fail)
- Chest tube tray at bedside (given absent L breath sounds)
- Type & Screen draw supplies ready for immediate draw on arrival
- Trauma team, respiratory therapy, and covering provider notified
- Expect transfer to Strong rather than CT scanning at Thompson once stabilized for transport
Patient arrives alert, pale, and diaphoretic. L chest has been decompressed by EMS. Breath sounds remain diminished on the left. Two large-bore IVs are in place from EMS. A left chest tube is inserted and immediately returns a large amount of blood. Initial assessment confirms massive bleeding from the chest/lung.
ED activation criteria:
- MTP activation should occur in patients with suspected or impending massive blood loss
- Strongly considered in patients requiring >2 units of PRBCs
- In the ED, the team should act on mechanism, chest tube blood output, and clinical picture — don't wait for lab confirmation
- There is no ED chart order called MTP. Providers place the transfusion and blood product orders after the fact and document activation in a provider note as required
- Role responsibilities: Primary RN/provider verify the T&S and identify need; ED team activates through Blood Bank; provider completes paperwork and later enters transfusion/product orders; charge nurse calls the nursing supervisor and delegates a runner; runner/designee takes the patient label to Blood Bank and brings back first products
Call Blood Bank at x6544 to activate MTP. Provide: patient name, DOB, MRN, ED location, ED phone number.
- The charge RN may have already notified Blood Bank that a possible MTP was inbound, but activation is only confirmed after arrival and provider assessment
- The ED physician completes the emergency release/cooler paperwork for Blood Bank
- The patient is pre-registered to expedite getting labels ready for Blood Bank
- The nursing supervisor coordinates ongoing cooler transport and any additional personnel/resources needed
- The cooler and completed paperwork must be returned to Blood Bank
A Type & Screen must be sent to the lab as soon as possible after patient arrival. Until the Type & Screen reaches Blood Bank, emergency uncrossmatched blood is used.
- The specimen must be in the correct pink-top tube with the correct patient label and collection information
- Delays or labeling problems keep the patient on emergency-release blood longer than necessary
- Once the T&S results, Blood Bank can transition to type-specific products
- CRITICAL SAFETY: If no historical blood type on file, an initial AND confirmatory T&S specimen must be collected at DIFFERENT times. Draw confirmatory before blood administration when feasible. Collecting specimens at different times reduces the risk of mislabeled specimens. This type of error could result in patient death.
- Runner/designee brings patient sticker (identifier) to Blood Bank for emergency release
- Blood Bank actions: emergency release paperwork, specific products prepared, Red Cross notification if needed
- Blood Bank issues emergency uncrossmatched blood: O-negative if the patient is female; O-positive or O-negative if the patient is male, until the Type & Screen reaches Blood Bank
- Standard MTP release pattern: PRBCs and cold-stored platelets travel in the cooler; FFP is thawed at 37°C and released separately/as available, often 2 at a time
- Runner/designee brings cooler to bedside
- As additional products become available, Blood Bank calls for cooler pickup and the nursing supervisor coordinates who goes to get them
- It is the receiving unit's responsibility to delegate a runner to pick up ongoing blood products
Critical ED difference:
- Emergency release products are uncrossmatched and may not follow the normal bedside barcode workflow
- The patient sticker/cooler paperwork must be returned to Blood Bank with the cooler
- Once the T&S results, Blood Bank can switch to type-specific (crossmatched) products that can be scanned normally
- This is a common point of confusion in the ED — the RN needs to know why the scanner won't work and what to do instead
- Verification/documentation before each transfusion: signed/verified with 2 patient identifiers, tag signed, emergency release paperwork signed by provider
- During active MTP: PRBC and FFP can go through the warmer/rapid infuser, and vital signs must be documented at the correct frequency
- FFP thaw time: discuss what products are available now and whether the patient is stable enough for transport
First cooler arrives with emergency-release products. Rapid transfusion is underway. Before complications hit, the ED team needs to get the product rules and paper trail right.
- PRBC and FFP can be administered via the blood warmer
- The rapid infuser can be used when clinically indicated
- These are the products the team will typically move fastest in active trauma MTP
- Platelets must go through standard blood tubing only
- Platelets and cryoprecipitate should never go through the warmer or rapid infuser
- Cryoprecipitate is at room temperature and is issued after 4 FFP
- Heat and pressure damage platelet function
- Every cooler should be checked on arrival
- Acceptable range is 1–10°C
- Above 10°C means the products should not be used and Blood Bank must be notified
The first cooler has arrived and rapid transfusion is underway. Now two common failure points show up back-to-back.
The provider orders: "Run everything through the warmer and rapid infuser — we need volume fast."
Do you see a problem with this order?
✓ ED RN catches the error — platelets and cryo are excluded from the warmer and rapid infuser. Administered correctly via standard blood tubing. Good catch under trauma pressure.
Teaching moment: Even in a trauma resuscitation where speed is critical, platelets and cryoprecipitate must NEVER go through a blood warmer or rapid infuser. Only PRBC and FFP can. Heat and pressure damage platelet function. The ED RN must speak up — even when the room is moving fast.
Second cooler arrives. Temperature reads 11°C.
What does the team do?
✓ Team identifies out-of-range temperature. Blood Bank notified at x6544. Cooler returned. Replacement dispatched.
11°C exceeds the maximum (1–10°C). Products must be returned — they will be discarded by Blood Bank. In the ED trauma setting, this creates a gap in product availability during active hemorrhage. Who checks the cooler temp when it arrives? The receiving RN should check every cooler immediately on arrival.
After aggressive resuscitation — 6 PRBC, 4 FFP, 1 dose platelets — patient is stabilizing enough for transport, but the L chest tube continues to show extensive bloody output. This patient would not likely be scanned at Thompson. Decision is made to transfer to Strong.
- Situation: Tractor crush chest injury, MTP activated, transfer to Strong
- Background: Mechanism, L chest decompression, chest tube insertion with extensive output, products given (6 PRBC, 4 FFP, 1 plt)
- Assessment: Stabilizing but still hemodynamically borderline
- Recommendation: Trauma care at Strong, clear product/handoff documentation, and local MTP discontinuation at transfer
- Discontinue MTP when the patient transfers to Strong
- Call Blood Bank x6544 so they stop preparing products for a patient leaving the facility
- Return the cooler and ED physician-completed paperwork to Blood Bank
- Document products already transfused and communicate that product story in the transfer handoff
- Secure IV lines and active infusions for transport
- Transfer team receives clear report on mechanism, chest tube output, products given, current vitals, and ongoing bleeding concern
- Appropriate transfer records go with the patient
- Cooler and ED Blood Bank paperwork return to Blood Bank locally
Use these questions to guide the team discussion. In self-guided mode, reflect on each question before moving on.
CC.03.004 — Massive Transfusion Process for Adult Patient
Blood Bank: x6544
How confident were you in managing an MTP in the ED?
How confident do you feel now in your ability to manage an MTP in the ED?