First 5 minutes critical patient
›Immediate stabilization
›Continuous monitoring
›Two large bore IV lines if unstable
›Oxygen if hypoxemia
›Hemorrhage control priorities
›Local pressure and hemostatic measures
›Activate massive transfusion protocol per local protocol
›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
›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
›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
›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
›Specialty consultation triggers
›Hematology for unexplained thrombocytopenia or coagulopathy
›Surgery or interventional radiology for uncontrolled bleeding source
›OB GYN for heavy uterine bleeding
›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