a. Bleeding

b. Assess for hemorrhagic shock (altered mental status in the absence of brain injury and/or weak or absent radial pulse).

c. IV/IO Access

d. Tranexamic Acid (TXA)

        OR

e. Fluid resuscitation

1. Cold stored low titer O whole blood

2. Pre-screened low titer O fresh whole blood

3. Plasma, red blood cells (RBCs) and platelets in a 1:1:1 ratio

4. Plasma and RBCs in a 1:1 ratio

5. Plasma or RBCs alone

NOTE: Hypothermia prevention measures [Section 7] should be initiated while fluid resuscitation is being accomplished.

If not in shock:

If in shock and blood products are available under an approved command or theater blood product administration protocol:

Given increased risk for a potentially lethal hemolytic reaction, transfusion of unscreened group O fresh whole blood or type specific fresh whole blood should only be performed under appropriate medical direction by trained personnel.

Transfusion should occur as soon as possible after life-threatening hemorrhage in order to keep the patient alive.  If Rh negative blood products are not immediately available, Rh positive blood products should be used in hemorrhagic shock.

If a casualty with an altered mental status due to suspected TBI has a weak or absent radial pulse, resuscitate as necessary to restore and maintain a normal radial pulse. If BP monitoring is available, maintain a target systolic BP between 100-110 mmHg.

Reassess the casualty frequently to check for recurrence of shock. If shock recurs, re-check all external hemorrhage control measures to ensure that they are still effective and repeat the fluid resuscitation as outlined above.

f. Refractory Shock