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so it can Everyone here may. I don't see the slides. Yeah, so it's just a quick run. Three off the massive transfusion protocol. So depending where you work, it might be the muscle transfusion Critical policy. Massive hemorrhage policy. Major hemorrhage Recall major trends you'd say massive transfusion protocol, massive transfusion guideline or a code red and essentially muscle transfuse. Your major hemorrhage is the replacement of the whole blood volume and less than 24 hours replacement of half the adult blood volume in asking four hours. So that's roughly 35 mills of blood per kilogram of body weight, transfusion of 40 miles per kilogram and Children, ongoing blood loss of 100 50 minutes per minute or a shock index of greater than 1.2. You see, that's where you take your heart, ripped and divide by your systolic BP. And so if your heart rate is higher than your BP, that's bad. If it's hired by factor bumping to you know it's made your hemorrhage. First step is to recognize major hemorrhage. Um, you can have for blood bank on extension. Here is 375733 and instead that you're activating the massive transfusion protocol. You can't ask for blood products, right? I committed up. But if you use the key words months of transfusion protocol and then everyone is aware of what's going on, they're aware that there might be a need for ongoing large volumes of the foot. Well, NASA otherwise date of my blood bank is sent up the Austrian supporter. So the first line, er, is 375, double away it or bleed 11 47. And that's the dedicated porter and the major Transfusion Protocol. It could be activated by any doctor or nurse on the on half of a named consultant, and ideally, that should be a designated individual dealing with blood bank. And they should have a dedicated for nine. So if the patient has a criminal sample already in the lab on Blood Bank will dispatch six units of red cells, they will start the thought for units of N, F. P, and ideally, two will be dispatched after 20 minutes and then three more held a blood bank should you need them. Two units of platelets are request from Belfast. Why they have to be thought on, then transported eso working Cause way it will be at least two yars into the months of transfusion policy Before you see any great that's right. There's also two units cryoprecipitates available on the past. And should you need ongoing blood products, they can be requested from blood Bank. If the patient doesn't have a group in hold sample in the lab, then you should take one before a minister in any product on. If that's the case, then they'll give you two units of negative red cells, two units of Great Baby FFP, which is universal again. We'll request two units of platelets from Belfast, two units of cryoprecipitates. It will be made available if you want them, and you confessed further products if you need them. There's also flying school blood. So this is for patients who haven't arrived in the E. D. Is yet. And so this is just on the basis of this down by cold. For the ambulance service, you can request this. It's activated in the same way as amounts of transfusion protocol. So if you form blood bank and say that you want flying squad blood Able Fair two units were negative sales and the cool box that will be sometime by Porter. And once it's opened, Pill Box and Cialis broken in half an hour to start transfusion it, and if you leave it in the corner of the room, it's good for four hours. So it gives you that little bit of regular um, and then decide whether or not you want. And depending on the state of the patient, you can give that blood on. Then activate the massive transfusion protocol. You can just request other rooms with individual units, uploaded blood products if you need them and where you can't stand it. DYN Nothing but find score Blood is there's a little laminated shape in the front of the standby book with all the contact details. Porter number two. So if you find yourself with a patient, you can use that in terms off a chest X blood products contrive either by the porter or by the chip system, or possibly buy both on. You should have a name to be his own person for blood bank, and they should have a dedicated full nine. Ideally, it should be one of the doctor phones because it's portable, hand on, like to be used by other people, and there should be a designated clinical team. Leader didn't with a patient, and they should be discussing the ongoing need for with the massive transfusion leaders in person and the ideal world to transfuse one in the red cells, one unit of entropy and one you know, platelets and I don't want to under one ratio. Obviously, it'll be two years or three contracts for his platelets. So in the meantime, if you try any interest close as, ah wonder, one ratio is possible between packed red cells and FFP. What you want to avoid is that what's comically in order to try out of them, so that is hypothermia, acidosis and quite a lot for face. They'll feed them together. So in a severe trauma, patient is bleeding and you get tissue hypoxia, which causes acidosis, which in Paris coagulation because is more bleeding and so on. If you then add in crystalloid fluids make a little bit hypothermic. You tell that they're charging factors, and again that feeds back in to see him look so whenever your transfusion patient with massive hemorrhage, there's some targets. The in four you want their temperature to be greater than 35. And with Warren blood blood products. Bear hug Ear's on whatever you need to do. Not. You want the pH greater than 7.2, and they're busy access last of minus six, and they're like it less than four. You want the ionized calcium, so the calcium level on the blood gas to be greater than 1.1, you give 10 to 20 million 10% calcium looking at or temper those of 10% calcium chloride. Try achieve up hemoglobin on its own isn't much us a massive damage. You can get him a concentration and so on. And so if you go by their physiological parameters high, they look on the ongoing blood loss. Platelets should be greater than 50 or greater than 100 if there's any intracranial bleed and the bathroom in time. In there, a PTT should be less than one half times normal, and that's why we give FFP to keep not in the target range. They're fibrinogen should be greater than one, um, and if it's not, give cryoprecipitates. You will try and keep their main arterial pressure and 65 millions of mercury and as well as giving blood. So you want to try and mentally in there circulating volume so you can directly compress external hammers. You can use hemostatic, agent tourniquets and so on and old big in trouble. Patients should have t X administered. If it's a G, I believe that you're worried about is the cause. Then you could give turn oppressing. If they're anticoagulated, then you could give a reversal agents, whether it's vitamin K, octaplas X and so on. And there's documents on that in the Resource Resources folder in the share drive, you can spend bone bone fractures you can use pelvic binder on. You want to keep the patient warm for a reward them. So are there any questions with that? Yeah, and thank you. And again, if it was got a quick comments or questions, they could put it into the shop. That child function there. Ah, things also just worth saying Cream. I think you mentioned that the human vaginal it's team will investigate every sort of the main treatment protocol been activated, So don't be alarmed when you get an email from the team asking your friend of feedback on it, just part of the normal process because we want to try and make it better each time. And invariably there are. She's with, um, with something. Let me do the Motrin. Average broke all purely because I don't know Frank often.