›Activate massive transfusion protocol per local protocol
Diagnostic sequencing
›Initial diagnostics
›CBC smear PT INR aPTT fibrinogen
›Type and screen
›Targeted diagnostics
›If schistocytes, PLASMIC score and TTP pathway
›If heparin exposure, 4T score and HIT testing
Transfusion thresholds
›Red blood cell transfusion
›Consider transfusion if hemoglobin < 70 g/L in stable hospitalized adults
›Higher threshold if ongoing ischemia or shock
›Platelet transfusion
›If platelets < 10 x10^9/L, consider prophylaxis based on context
›If active bleeding, consider transfusion if platelets < 50 x10^9/L
›If intracranial hemorrhage, consider higher platelet target per specialist guidance
Coagulopathy correction
›Fibrinogen replacement
›If fibrinogen < 1.5 g/L with bleeding, cryoprecipitate per local protocol
›Recheck fibrinogen after replacement
›Vitamin K
›Vitamin K IV 5 mg
›Vitamin K IV 10 mg
Anticoagulant reversal
›Warfarin associated major bleeding
›Four factor PCC per weight based protocol
›Vitamin K IV 10 mg
›Dabigatran associated major bleeding
›Idarucizumab IV 5 g
›Hemodialysis consideration if renal failure and severe bleed
›Factor Xa inhibitor associated major bleeding
›Andexanet alfa local protocol dependent
›Four factor PCC local protocol dependent
Platelet dysfunction therapies
›DDAVP
›DDAVP IV 0.3 mcg per kg over 20 to 30 minutes
›Avoid in hyponatremia risk
›Antifibrinolytic
›Tranexamic acid IV 1 g
›Repeat dose IV 1 g after 8 hours local protocol dependent
Disease specific pathways
›TTP suspected
›If high suspicion, initiate emergent hematology pathway
›Plasma exchange urgency
›ITP suspected
›If significant bleeding, corticosteroid initiation per guideline
›IVIG consideration in severe bleeding
Consultation
›Specialty consultation triggers
›Hematology for unexplained thrombocytopenia or coagulopathy
›Surgery or interventional radiology for uncontrolled bleeding source
›OB GYN for heavy uterine bleeding
Reassessment loop
›Reassessment timing
›Repeat vitals every 15 minutes if unstable
›Repeat CBC and coagulation labs after major intervention
›Escalation triggers
›If rising transfusion requirement, ICU
›If new neurologic symptoms, immediate CT head
17Disposition/dispo28
ICU criteria
›ICU indications
›Hemodynamic instability requiring vasopressors
›Massive transfusion protocol activation
›Suspected intracranial hemorrhage
›High risk hematology emergencies
›TTP suspected
›DIC with active bleeding
Inpatient admission criteria
›Admission indications
›Platelets < 20 x10^9/L with bleeding
›New severe coagulopathy
›Need for ongoing transfusion
›Monitoring needs
›Serial hemoglobin trend
›Serial neurologic checks
Observation pathway
›Observation candidates
›Stable vitals
›Controlled bleeding source
›Clear outpatient follow up within 24 to 72 hours
›Observation exclusions
›Unreliable follow up
›High risk medication that cannot be safely held
Discharge criteria
›Discharge requirements
›No ongoing bleeding
›Stable hemoglobin trend
›Platelets stable and not critically low
›Follow up timing
›Hematology follow up within 72 hours if new thrombocytopenia
›Primary care follow up within 7 days
18Discharge Instructions/di23
Copy discharge instructions
›Summary
›You were seen for unexplained bruising or bleeding
›Your tests today suggest a bleeding tendency that needs follow up
›Medications
›Avoid NSAIDs unless specifically instructed
›Take prescribed medicines exactly as directed
›Do not restart blood thinners unless your clinician tells you to
›Activity
›Avoid contact sports until cleared
›Use soft toothbrush
›Follow up
›Follow up with your clinician within 1 to 3 days if labs were abnormal
›Arrange hematology follow up if recommended
›Return now
›Any severe headache
›Any new weakness
›Trouble speaking
›Fainting
›Vomiting blood
›Black stools
›Heavy vaginal bleeding
›Blood in urine
›Bleeding that does not stop with 10 minutes of pressure
19References/r6
Guidelines and decision tools
›Reference set
›American Society of Hematology guideline for immune thrombocytopenia, 2019
›American Society of Hematology guideline review and update process for immune thrombocytopenia, 2024
›AABB International Guidelines for Red Blood Cell Transfusion, 2023
›American College of Cardiology Expert Consensus Decision Pathway on management of bleeding in patients on oral anticoagulants, 2020
›International Society on Thrombosis and Haemostasis disseminated intravascular coagulation scoring guidance, 2001
Evidence & Review
Reviewed by SymptomDx Medical Team·Last reviewed
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.