Approach to the critical patient first 5 minutes
›Stabilization priorities
›Cardiac monitor
›Pulse oximetry
›Frequent blood pressure cycling
›Two large bore IVs if unstable or active bleeding
›Oxygen if hypoxic or respiratory distress
›Immediate tests and targets
›CBC and type and screen within 30 minutes if transfusion possible
›ECG within 10 minutes if chest pain or syncope
›Point of care glucose if altered mental status
›Early activation triggers
›If shock, activate massive hemorrhage protocol per local protocol dependent
›If suspected ectopic pregnancy with instability, immediate OB GYN involvement
›If ischemia, cardiology pathway per local protocol dependent
Transfusion strategy and thresholds
›RBC transfusion indications
›Hemoglobin less than 70 g/L in stable adults suggests transfusion threshold in many restrictive strategies local protocol dependent
›Higher threshold may be appropriate with active ischemia or ongoing bleeding local protocol dependent
›Transfusion dosing and monitoring
›1 unit PRBC then reassess symptoms and vitals
›Recheck hemoglobin after 1 to 2 units or sooner if ongoing bleeding
›Monitor for transfusion reaction
›Transfusion cautions
›Heart failure risk for TACO
›Hypocalcemia risk with massive transfusion
›Hyperkalemia risk with older blood or massive transfusion
Etiology directed treatment
›Suspected GI bleeding
›IV crystalloid only as bridge to blood products in hemorrhagic shock
›PPI therapy when upper GI bleed suspected local protocol dependent
›GI consultation for endoscopy timing local protocol dependent
›Suspected heavy uterine bleeding
›Tranexamic acid dosing per local protocol dependent
›Gynecology consultation triggers
›Suspected hemolysis
›If autoimmune hemolysis suspected, hematology consultation
›If thrombotic microangiopathy suspected, urgent specialty escalation
›Iron deficiency without instability
›Oral iron as outpatient when stable and cause addressed local protocol dependent
›IV iron consideration when malabsorption or intolerance local protocol dependent
›Underproduction workup when indicated
›Reticulocyte count interpretation branch
›Smear review for blasts
›Consider marrow evaluation if pancytopenia or blasts
›Blood loss workup when indicated
›Identify overt bleeding source
›Imaging or endoscopy pathway per stability and local protocol dependent
›Timed reassessment
›Repeat vitals every 15 to 30 minutes if moderate to severe symptoms
›Repeat symptom check after each unit transfused
›Repeat exam for new bleeding
›Disposition changing findings
›New chest pain
›New hypoxia
›Persistent tachycardia despite transfusion and fluids