1st priority: restore volume with fluid.• Two large bore IVs (14 or 16 gauge)

*Shorter tubing provides faster IV rate

2nd prority: restore volume with Whole Blood and transfusion.

• Judicious use of crystalloid in Class II Hemorrhage or higher*ATLS and textbooks still describe the use of NS or LR for 1-2 Liter bolus*However, new guidelines suggest limiting crystalloid in favor of Blood Products

3rd priority: normalize coagulation status with FFP, platelets and blood products.

• Hemorrhage should be replaced with Blood Products*Indications

• Mean arterial pressure 65 (or systolic Blood Pressure 70-90 mmHg)

• Poor response to IV fluids– Persistent Tachycardia, Hypotension or Tachyp

nea– Urine output <50 ml/hour (<1ml/kg/hour)

*Start with 2 units (prepare 4 units pRBC for more severe Hemorrhage)

• Type specific blood can be ready within 30-40 minutes

• In the crashing patient give unmatched type-specific blood, Low titer O or O negative blood

*Massive Hemorrhage with administration of more than 4 units requires matching Blood Products*Consider autotransfusion (e.g. Hemovac or Cell Saver)

• Indicated for massive bleeding if blood can be drained and not contaminated)

*Consider blood warmer