1. Hospitals must have a major haemorrhage protocol in place and this should include clinical, laboratory and logistic responses. 2. Immediate control of obvious bleeding is of paramount importance (pressure, tourniquet, haemostatic dressings). 3. The major haemorrhage protocol must be mobilised immediately when a massive haemorrhage situation is declared. 4. A fibrinogen < 1 g.l~(-1) or a prothrombin time (PT) and activated partial thromboplastin time (aPTT) of > 1.5 times normal represents established haemostatic failure and is predictive of microvascular bleeding. Early infusion of fresh frozen plasma (FFP; 15 ml.kg~(-1) ) should be used to prevent this occurring if a senior clinician anticipates a massive haemorrhage. 5. Established coagulopathy will require more than 15 ml.kg~(-1) of FFP to correct. The most effective way to achieve fibrinogen replacement rapidly is by giving fibrinogen concentrate or cryoprecipitate if fibrinogen is unavailable.
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