BleedQ

Critical Bleed Navigator

Last updated:

Select a scenario: Which bleeding situation is being managed?

DOAC

This is a scenario-based simulator. No patient information should be entered, and the tool does not record what you enter.

What is the situation?

Bleed on DOAC

What is the type of bleed?

Minor bleeding

Minor BleedFor example: extremity bruising, hemorrhoidal bleeding, subconjunctival bleed, self-limited epistaxis.

Is minor bleeding confirmed?

Yes

Last updated: 16-JUL-2026
Source
  • Thrombosis Canada, 2025
No PCC is approved in Canada for this indication
Manage

Minor bleeding on DOAC

  1. 1

    Continue DOAC and monitor

  2. 2

    Confirm the patient is receiving the appropriate drug and dose based on indication, age, weight, creatinine clearance, co-medications.

  3. 3

    Consider measuring hemoglobin, platelet count, creatinine, and liver function tests

  4. 4

    Review concomitant medications which may contribute to bleeding (e.g. antiplatelet therapies, NSAIDs, SSRIs, herbal supplements)

As directed by protocol

Is management complete and bleeding resolved?

Yes

Termination

Bleeding resolved

  1. 1

    Assess patients for resumption of anticoagulation when hemostasis is achieved with consideration of shared decision making

  2. 2

    Confirm ongoing indication for anticoagulation.

  3. 3

    Estimate the risks of recurrent bleeding and thrombosis (and their clinical sequelae) with multidisciplinary input.

  4. 4

    Re-evaluate laboratory parameters once patient has been clinically stabilized (hemoglobin, platelet count, creatinine, liver function tests) and patient’s weight.

  5. 5

    Review concomitant medications and reassess the need for medications which may contribute to bleeding (i.e. antiplatelet therapies, NSAIDs, SSRIs, herbal supplements)

  6. 6

    Confirm the appropriateness of the type and dose of anticoagulant based on clinical characteristics such as indication, age, weight, and creatinine clearance.

  7. 7

    Provide education and counselling regarding bleeding complications and when to seek medical attention.

  8. 8

    Ensure routine follow-up and reassessment of #1 to #6 at regular intervals.

As directed by protocol

Scenario complete

Reset to start over or to select another scenario

AcknowledgementsAdapted from Thrombosis Canada clinical guide "DOACs: Management of Bleeding" with clinical oversight by Dr. Joseph Shaw.

Clinically relevant non-major bleeding

Clinically relevant non-major bleedingNon-life-threatening bleeding that requires medical attention and/or non-urgent intervention (i.e. hemodynamically stable chronic gastrointestinal bleed, epistaxis, hematuria, or menstrual bleeding)

Is clinically relevant non-major bleeding confirmed?

Yes

What is the DOAC?

Apixaban

Which laboratory tests are available?

  • PT/INR
  • aPTT
  • Heparin or LMWH anti-Xa
  • Calibrated FXaI level (anti-Xa assay with FXaI-specific calibrators)

When was the timing of the last DOAC dose?

Next

Creatinine clearance (mL/min)

Next

Last updated: 16-JUL-2026
Source
  • Thrombosis Canada, 2025
No PCC is approved in Canada for this indication; use is guideline-supported
1 of 3

Clinically relevant non-major bleed on Apixaban

  1. 1

    Hold: DOAC therapy

  2. 2

    Apply: local hemostatic measures if appropriate (i.e. compression, packing, suturing)

  3. 3

    Measure: hemoglobin, platelet count, coagulation tests (PT/INR, aPTT), creatinine, liver function tests, group and screen (as appropriate) 

As directed by protocol

Next

Disclaimer

DOAC-specific calibrated anti-Xa assays remain the preferred method for measuring direct factor Xa inhibitor concentrations. LMWH-calibrated anti-Xa assays should not be used interchangeably across centers or assumed to directly provide a DOAC level in ng/mL. Their performance is assay-, reagent-, analyzer-, and drug-specific, and the IU/mL output requires careful local validation before clinical use. Where a center uses an LMWH-calibrated anti-Xa assay as a surrogate for apixaban, rivaroxaban, or edoxaban measurement, the laboratory should provide assay-specific interpretive guidance, including locally validated cutoffs or approximate conversion ranges to clinically relevant DOAC concentrations, the reportable/roughly linear range, and important limitations. This approach should only be used when such local validation and reporting infrastructure are in place.

2 of 3

Clinically relevant non-major bleed on Apixaban

  1. 1

    Measure: plasma concentration of DOAC using a specific validated assay (heparin or LMWH anti-Xa, FXaI-specific calibrated anti-Xa) if available with timely results AND the results would change management

    See disclaimer

  2. 2

    Determine: whether clinically significant levels of FXaI are likely to be present

As directed by protocol

PT/INR

PT/INR

IF

Normal

THEN
does NOT exclude a clinically significant FXaI level

IF

Increased

THEN
May indicate a clinically significant FXaI level

aPTT

aPTT

IF

Normal

THEN
Does NOT exclude a clinically significant FXaI level

IF

Increased

THEN
may indicate a clinically significant FXaI level

Heparin or LMWH anti-Xa

Heparin or LMWH anti Xa

IF

<0.1 IU/mL

THEN
likely no clinically significant FXaI level

IF

>0.1 IU/mL

THEN
possible clinically significant FXaI level

(assay dependent)

Calibrated FXaI level (anti-Xa assay with FXaI-specific calibrators)

Calibrated FXaI level

IF

<50 ng/mL

THEN
FXaI level less likely to be significantly contributing to impaired hemostasis

IF

>50 ng/mL

THEN
FXaI level is likely to be significantly contributing to impaired hemostasis

Next

3 of 3

Clinically relevant non-major bleed on Apixaban

  1. 1

    Determine the expected rate of drug clearance based on:

    Time elapsed since last Apixaban dose:

    • —

    Creatinine clearance:

    • —
    • —

    And:

    CrCl ≥ 50 mL/ min

    Half-life is 8-12 hours 

    Acute or worsening renal dysfunction

    Drug exposure may be increased and clearance delayed. Published half-life estimates are variable, and no reliable AKI-specific estimate is available.  

  2. 2

    If indicated, administer transfusion therapies as per guidelines.

  3. 3

    Seek consultation for investigation and definitive management of bleeding source as appropriate (i.e. endoscopy, interventional radiology, surgery)

As directed by protocol

Is management complete and bleeding resolved?

Yes

Termination

Bleeding resolved

  1. 1

    Assess patients for resumption of anticoagulation when hemostasis is achieved with consideration of shared decision making

  2. 2

    Confirm ongoing indication for anticoagulation.

  3. 3

    Estimate the risks of recurrent bleeding and thrombosis (and their clinical sequelae) with multidisciplinary input.

  4. 4

    Re-evaluate laboratory parameters once patient has been clinically stabilized (hemoglobin, platelet count, creatinine, liver function tests) and patient’s weight.

  5. 5

    Review concomitant medications and reassess the need for medications which may contribute to bleeding (i.e. antiplatelet therapies, NSAIDs, SSRIs, herbal supplements)

  6. 6

    Confirm the appropriateness of the type and dose of anticoagulant based on clinical characteristics such as indication, age, weight, and creatinine clearance.

  7. 7

    Provide education and counselling regarding bleeding complications and when to seek medical attention.

  8. 8

    Ensure routine follow-up and reassessment of #1 to #6 at regular intervals.

As directed by protocol

Scenario complete

Reset to start over or to select another scenario

AcknowledgementsAdapted from Thrombosis Canada's clinical guide "DOACs: Management of Bleeding" and the PROXY study (Schulman et. al, 2024) with clinical oversight by Dr. Joseph Shaw.

Edoxaban

Which laboratory tests are available?

  • PT/INR
  • aPTT
  • Heparin or LMWH anti-Xa
  • Calibrated FXaI level (anti-Xa assay with FXaI-specific calibrators)

When was the timing of the last DOAC dose?

Next

Creatinine clearance (mL/min)

Next

Last updated: 16-JUL-2026
Source
  • Thrombosis Canada, 2025
No PCC is approved in Canada for this indication; use is guideline-supported
1 of 3

Clinically relevant non-major bleed on Edoxaban

  1. 1

    Hold: DOAC therapy

  2. 2

    Apply: local hemostatic measures if appropriate (i.e. compression, packing, suturing)

  3. 3

    Measure: hemoglobin, platelet count, coagulation tests (PT/INR, aPTT), creatinine, liver function tests, group and screen (as appropriate) 

As directed by protocol

Next

Disclaimer

DOAC-specific calibrated anti-Xa assays remain the preferred method for measuring direct factor Xa inhibitor concentrations. LMWH-calibrated anti-Xa assays should not be used interchangeably across centers or assumed to directly provide a DOAC level in ng/mL. Their performance is assay-, reagent-, analyzer-, and drug-specific, and the IU/mL output requires careful local validation before clinical use. Where a center uses an LMWH-calibrated anti-Xa assay as a surrogate for apixaban, rivaroxaban, or edoxaban measurement, the laboratory should provide assay-specific interpretive guidance, including locally validated cutoffs or approximate conversion ranges to clinically relevant DOAC concentrations, the reportable/roughly linear range, and important limitations. This approach should only be used when such local validation and reporting infrastructure are in place.

2 of 3

Clinically relevant non-major bleed on Edoxaban

  1. 1

    Measure: plasma concentration of DOAC using a specific validated assay (heparin or LMWH anti-Xa, FXaI-specific calibrated anti-Xa) if available with timely results AND the results would change management

    See disclaimer

  2. 2

    Determine: whether clinically significant levels of FXaI are likely to be present

As directed by protocol

PT/INR

PT/INR

IF

Normal

THEN
does NOT exclude a clinically significant FXaI level

IF

Increased

THEN
May indicate a clinically significant FXaI level

aPTT

aPTT

IF

Normal

THEN
Does NOT exclude a clinically significant FXaI level

IF

Increased

THEN
may indicate a clinically significant FXaI level

Heparin or LMWH anti-Xa

Heparin or LMWH anti Xa

IF

<0.1 IU/mL

THEN
likely no clinically significant FXaI level

IF

>0.1 IU/mL

THEN
possible clinically significant FXaI level

(assay dependent)

Calibrated FXaI level (anti-Xa assay with FXaI-specific calibrators)

Calibrated FXaI level

IF

<50 ng/mL

THEN
FXaI level less likely to be significantly contributing to impaired hemostasis

IF

>50 ng/mL

THEN
FXaI level is likely to be significantly contributing to impaired hemostasis

Next

3 of 3

Clinically relevant non-major bleed on Edoxaban

  1. 1

    Determine the expected rate of drug clearance based on:

    Time elapsed since last Edoxaban dose:

    • —

    Creatinine clearance:

    • —
    • —

    And:

    CrCl ≥ 50 mL/ min

    Half-life is 10-14 hours

    Acute or worsening renal dysfunction

    Drug exposure may be increased and half-life may be prolonged, particularly with severe renal impairment. No reliable AKI-specific estimate is available.

  2. 2

    If indicated, administer transfusion therapies as per guidelines.

  3. 3

    Seek consultation for investigation and definitive management of bleeding source as appropriate (i.e. endoscopy, interventional radiology, surgery)

As directed by protocol

Is management complete and bleeding resolved?

Rivaroxaban

Which laboratory tests are available?

  • PT/INR
  • aPTT
  • Heparin or LMWH anti-Xa
  • Calibrated FXaI level (anti-Xa assay with FXaI-specific calibrators)

When was the timing of the last DOAC dose?

Next

Creatinine clearance (mL/min)

Next

Last updated: 16-JUL-2026
Source
  • Thrombosis Canada, 2025
No PCC is approved in Canada for this indication; use is guideline-supported
1 of 3

Clinically relevant non-major bleed on Rivaroxaban

  1. 1

    Hold: DOAC therapy

  2. 2

    Apply: local hemostatic measures if appropriate (i.e. compression, packing, suturing)

  3. 3

    Measure: hemoglobin, platelet count, coagulation tests (PT/INR, aPTT), creatinine, liver function tests, group and screen (as appropriate) 

As directed by protocol

Next

Disclaimer

DOAC-specific calibrated anti-Xa assays remain the preferred method for measuring direct factor Xa inhibitor concentrations. LMWH-calibrated anti-Xa assays should not be used interchangeably across centers or assumed to directly provide a DOAC level in ng/mL. Their performance is assay-, reagent-, analyzer-, and drug-specific, and the IU/mL output requires careful local validation before clinical use. Where a center uses an LMWH-calibrated anti-Xa assay as a surrogate for apixaban, rivaroxaban, or edoxaban measurement, the laboratory should provide assay-specific interpretive guidance, including locally validated cutoffs or approximate conversion ranges to clinically relevant DOAC concentrations, the reportable/roughly linear range, and important limitations. This approach should only be used when such local validation and reporting infrastructure are in place.

2 of 3

Clinically relevant non-major bleed on Rivaroxaban

  1. 1

    Measure: plasma concentration of DOAC using a specific validated assay (heparin or LMWH anti-Xa, FXaI-specific calibrated anti-Xa) if available with timely results AND the results would change management

    See disclaimer

  2. 2

    Determine: whether clinically significant levels of FXaI are likely to be present

As directed by protocol

PT/INR

PT/INR

IF

Normal

THEN
does NOT exclude a clinically significant FXaI level

IF

Increased

THEN
May indicate a clinically significant FXaI level

aPTT

aPTT

IF

Normal

THEN
Does NOT exclude a clinically significant FXaI level

IF

Increased

THEN
may indicate a clinically significant FXaI level

Heparin or LMWH anti-Xa

Heparin or LMWH anti Xa

IF

<0.1 IU/mL

THEN
likely no clinically significant FXaI level

IF

>0.1 IU/mL

THEN
possible clinically significant FXaI level

(assay dependent)

Calibrated FXaI level (anti-Xa assay with FXaI-specific calibrators)

Calibrated FXaI level

IF

<50 ng/mL

THEN
FXaI level less likely to be significantly contributing to impaired hemostasis

IF

>50 ng/mL

THEN
FXaI level is likely to be significantly contributing to impaired hemostasis

Next

3 of 3

Clinically relevant non-major bleed on Rivaroxaban

  1. 1

    Determine the expected rate of drug clearance based on:

    Time elapsed since last Rivaroxaban dose:

    • —

    Creatinine clearance:

    • —
    • —

    And:

    CrCl ≥ 50 mL/ min

    Half-life is 7-11 hours

    Acute or worsening renal dysfunction

    Drug exposure may be increased, although stable renal impairment causes only modest prolongation of the terminal half-life. No reliable AKI-specific estimate is available.

  2. 2

    If indicated, administer transfusion therapies as per guidelines.

  3. 3

    Seek consultation for investigation and definitive management of bleeding source as appropriate (i.e. endoscopy, interventional radiology, surgery)

As directed by protocol

Is management complete and bleeding resolved?

Dabigatran 

Which laboratory tests are available?

  • PT/INR
  • aPTT
  • Dilute TT or Ecarin time
  • Thrombin Time

When was the timing of the last DOAC dose?

Next

Creatinine clearance (mL/min)

Next

Last updated: 16-JUL-2026
Source
  • Thrombosis Canada, 2025
No PCC is approved in Canada for this indication; use is guideline-supported
1 of 3

Clinically relevant non-major bleed on Dabigatran

  1. 1

    Hold: DOAC therapy

  2. 2

    Apply: local hemostatic measures if appropriate (i.e. compression, packing, suturing)

  3. 3

    Measure: hemoglobin, platelet count, coagulation tests (PT/INR, aPTT), creatinine, liver function tests, group and screen (as appropriate) 

As directed by protocol

Next

2 of 3

Clinically relevant non-major bleed on Dabigatran

  1. 1

    Measure: plasma concentration of DOAC using a specific validated assay (Dilute TT OR ECT AND thrombin time) if available with timely results AND the results would change management

  2. 2

    Determine: whether clinically significant levels of Dabigatran are likely to be present

As directed by protocol

PT/INR

PT/INR

IF

Normal

THEN
does NOT exclude a clinically significant Dabigatran level

IF

Increased

THEN
May indicate a clinically significant Dabigatran level

aPTT

aPTT

IF

Normal

THEN
Does NOT exclude a clinically significant Dabigatran level

IF

Increased

THEN
may indicate a clinically significant Dabigatran level

Dilute TT or Ecarin time

Dilute TT or Ecarin time

IF

<50ng/mL

THEN
Dabigatran level less likely to be significantly contributing to impaired hemostasis

IF

>50ng/mL

THEN
Dabigatran level is likely to be significantly contributing to impaired hemostasis

Thrombin Time

Thrombin Time

IF

Normal

THEN
no Dabigatran present

IF

Increased

THEN
Some Dabigatran effect

Next

3 of 3

Clinically relevant non-major bleed on Dabigatran

  1. 1

    Determine the expected rate of drug clearance based on:

    Time elapsed since last Dabigatran dose:

    • —

    Creatinine clearance:

    • —
    • —

    And:

    CrCl >80 mL/min

    Half-life is 13.4 hours

    CrCl >50 to ≤80 mL/min

    Half-life is 15.3 hours

    CrCl >30 to ≤50 mL/min

    Half-life is 18.4 hours

    CrCl ≤30 mL/min

    Half-life is 27.2 hours

  2. 2

    If indicated, administer transfusion therapies as per guidelines.

  3. 3

    Seek consultation for investigation and definitive management of bleeding source as appropriate (i.e. endoscopy, interventional radiology, surgery)

As directed by protocol

Is management complete and bleeding resolved?

Major bleeding

Major bleeding Severe/life threatening bleeding (i.e. bleeding in a critical area or organ, such as intracranial, intraspinal or epidural, retroperitoneal, intramuscular with actual or impending compartment syndrome, pericardial, gastrointestinal bleeding with hemodynamic instability)

Is major bleeding confirmed?

Yes

What is the DOAC?

Apixaban

Which laboratory tests are available?

  • PT/INR
  • aPTT
  • Heparin or LMWH anti-Xa
  • Calibrated FXaI level (anti-Xa assay with FXaI-specific calibrators)

When was the timing of the last DOAC dose?

Next

Creatinine clearance (mL/min)

Next

Last updated: 16-JUL-2026
Source
  • Thrombosis Canada, 2025
No PCC is approved in Canada for this indication; use is guideline-supported
1 of 3

Major bleed on Apixaban

  1. 1

    Hold: DOAC therapy

  2. 2

    Initiate: resuscitation in a monitored setting

  3. 3

    Apply: local hemostatic measures if appropriate (i.e. compression, packing, suturing)

  4. 4

    Consult: an expert urgently for advice regarding management of coagulopathy (i.e. hematologist, internist, ER physician, pharmacist) and consult for definitive procedural intervention as applicable (i.e. gastroenterology, interventional radiology, surgery)

  5. 5

    STAT: laboratory testing for hemoglobin, platelet count, coagulation tests (PT/INR, aPTT), creatinine, liver function tests, group and screen (as appropriate)

As directed by protocol

Next

Disclaimer

DOAC-specific calibrated anti-Xa assays remain the preferred method for measuring direct factor Xa inhibitor concentrations. LMWH-calibrated anti-Xa assays should not be used interchangeably across centers or assumed to directly provide a DOAC level in ng/mL. Their performance is assay-, reagent-, analyzer-, and drug-specific, and the IU/mL output requires careful local validation before clinical use. Where a center uses an LMWH-calibrated anti-Xa assay as a surrogate for apixaban, rivaroxaban, or edoxaban measurement, the laboratory should provide assay-specific interpretive guidance, including locally validated cutoffs or approximate conversion ranges to clinically relevant DOAC concentrations, the reportable/roughly linear range, and important limitations. This approach should only be used when such local validation and reporting infrastructure are in place.

2 of 3

Major bleed on Apixaban

  1. 1

    Measure: plasma concentration of DOAC using a specific validated assay (heparin or LMWH anti-Xa, FXaI-specific calibrated anti-Xa) if available with timely results AND the results would change management

    See disclaimer

  2. 2

    Determine: whether clinically significant levels of FXaI are likely to be present

As directed by protocol

PT/INR

PT/INR

IF

Normal

THEN
does NOT exclude a clinically significant FXaI level

IF

Increased

THEN
May indicate a clinically significant FXaI level

aPTT

aPTT

IF

Normal

THEN
Does NOT exclude a clinically significant FXaI level

IF

Increased

THEN
may indicate a clinically significant FXaI level

Heparin or LMWH anti-Xa

Heparin or LMWH anti Xa

IF

<0.1 IU/mL

THEN
likely no clinically significant FXaI level

IF

>0.1 IU/mL

THEN
possible clinically significant FXaI level

(assay dependent)

Calibrated FXaI level (anti-Xa assay with FXaI-specific calibrators)

Calibrated FXaI level

IF

<30 ng/mL

THEN
FXaI level is not significantly contributing to impaired hemostasis

IF

30-50ng/mL

THEN
FXaI level less likely to be significantly contributing to impaired hemostasis

IF

>50 ng/mL

THEN
FXaI level is likely to be significantly contributing to impaired hemostasis

Next

Note

<30 ng/mL: Residual FXaI level is unlikely to be a major contributor to ongoing impaired hemostasis. At this level, the DOAC effect alone would generally not justify PCC administration, and management should instead focus on local hemostatic measures, supportive care, source control, transfusion support as needed, and the overall clinical context. This threshold does not exclude all bleeding risk, but it suggests that residual anticoagulant effect is less likely to be the main driver of bleeding.

30 to 50 ng/mL: Residual FXaI level may still be clinically relevant, but this range should be treated as a gray zone. In many patients, especially those without catastrophic bleeding, PCC may still be deferred. However, PCC can be considered when the clinical situation is especially high risk, such as life-threatening bleeding, bleeding at a critical site such as intracranial hemorrhage, or urgent surgery or intervention with very high bleeding risk that cannot be delayed. In this range, interpretation should be individualized and based on the severity of bleeding, the anatomic site, procedural urgency, and whether a specific reversal agent is available.

>50 ng/mL: Residual FXaI level is more likely to be clinically significant and more likely to be contributing meaningfully to impaired hemostasis. In patients with major or life-threatening bleeding, or those requiring urgent or emergency high bleeding risk surgery, this level would support consideration of PCC, particularly when a specific antidote is unavailable. For urgent procedural decision-making, the acceptable threshold may vary with the bleeding risk of the planned intervention, and some situations may justify use of a higher threshold in the 50 to 75 ng/mL range depending on surgical context.

Interpretive note: These thresholds should support, not replace, clinical judgment. Decisions about PCC should still be driven primarily by bleeding severity, bleeding site, procedural urgency, and whether definitive local hemostasis or delay to permit drug clearance is feasible. In general, 50 ng/mL is a reasonable threshold for considering reversal in major bleeding, whereas 30 ng/mL may be considered in particularly severe or life-threatening bleeding.

3 of 3

Major bleed on Apixaban

  1. 1

    Determine the expected rate of drug clearance based on:

    Time elapsed since last Apixaban dose:

    • —

    Patient’s creatinine clearance:

    • —
    • —

    And:

    CrCl ≥ 50 mL/ min

    Half-life is 8-12 hours 

    Acute or worsening renal dysfunction

    Drug exposure may be increased and clearance delayed. Published half-life estimates are variable, and no reliable AKI-specific estimate is available.  

  2. 2

    If clinically significant FXaI levels are likely to be present based on:

    • Age
    • Weight
    • Renal/hepatic function
    • Concurrent interacting medications
    • Time since last Apixaban dose


    OR level is confirmed using a FXaI-specific assay (levels over 30 to 50ng/mL) - See Note

As directed by protocol

Protocol directs: Administer PCC

Dose

2000 units fixed dose or 25-50 units/kg, maximum single dose of 5000 IU

Safety

Contraindicated in patients with a history of heparin-induced thrombocytopenia

Note

PCC is not a specific reversal agent but the only available prohemostatic therapy

Consult local institutional protocols or hematology/thrombosis for advice as required and inform patients/ families regarding thrombotic risks.

Is management complete and bleeding resolved?

Edoxaban

Which laboratory tests are available?

  • PT/INR
  • aPTT
  • Heparin or LMWH anti-Xa
  • Calibrated FXaI level (anti-Xa assay with FXaI-specific calibrators)

When was the timing of the last DOAC dose?

Next

Creatinine clearance (mL/min)

Next

Last updated: 16-JUL-2026
Source
  • Thrombosis Canada, 2025
No PCC is approved in Canada for this indication; use is guideline-supported
1 of 3

Major bleed on Edoxaban

  1. 1

    Hold: DOAC therapy

  2. 2

    Initiate: resuscitation in a monitored setting

  3. 3

    Apply: local hemostatic measures if appropriate (i.e. compression, packing, suturing)

  4. 4

    Consult: an expert urgently for advice regarding management of coagulopathy (i.e. hematologist, internist, ER physician, pharmacist) and consult for definitive procedural intervention as applicable (i.e. gastroenterology, interventional radiology, surgery)

  5. 5

    STAT: laboratory testing for hemoglobin, platelet count, coagulation tests (PT/INR, aPTT), creatinine, liver function tests, group and screen (as appropriate)

As directed by protocol

Next

Disclaimer

DOAC-specific calibrated anti-Xa assays remain the preferred method for measuring direct factor Xa inhibitor concentrations. LMWH-calibrated anti-Xa assays should not be used interchangeably across centers or assumed to directly provide a DOAC level in ng/mL. Their performance is assay-, reagent-, analyzer-, and drug-specific, and the IU/mL output requires careful local validation before clinical use. Where a center uses an LMWH-calibrated anti-Xa assay as a surrogate for apixaban, rivaroxaban, or edoxaban measurement, the laboratory should provide assay-specific interpretive guidance, including locally validated cutoffs or approximate conversion ranges to clinically relevant DOAC concentrations, the reportable/roughly linear range, and important limitations. This approach should only be used when such local validation and reporting infrastructure are in place.

2 of 3

Major bleed on Edoxaban

  1. 1

    Measure: plasma concentration of DOAC using a specific validated assay (heparin or LMWH anti-Xa, FXaI-specific calibrated anti-Xa) if available with timely results AND the results would change management

    See disclaimer

  2. 2

    Determine: whether clinically significant levels of FXaI are likely to be present

As directed by protocol

PT/INR

PT/INR

IF

Normal

THEN
does NOT exclude a clinically significant FXaI level

IF

Increased

THEN
May indicate a clinically significant FXaI level

aPTT

aPTT

IF

Normal

THEN
Does NOT exclude a clinically significant FXaI level

IF

Increased

THEN
may indicate a clinically significant FXaI level

Heparin or LMWH anti-Xa

Heparin or LMWH anti Xa

IF

<0.1 IU/mL

THEN
likely no clinically significant FXaI level

IF

>0.1 IU/mL

THEN
possible clinically significant FXaI level

(assay dependent)

Calibrated FXaI level (anti-Xa assay with FXaI-specific calibrators)

Calibrated FXaI level

IF

<30 ng/mL

THEN
FXaI level is not significantly contributing to impaired hemostasis

IF

30-50ng/mL

THEN
FXaI level less likely to be significantly contributing to impaired hemostasis

IF

>50 ng/mL

THEN
FXaI level is likely to be significantly contributing to impaired hemostasis

Next

Note

<30 ng/mL: Residual FXaI level is unlikely to be a major contributor to ongoing impaired hemostasis. At this level, the DOAC effect alone would generally not justify PCC administration, and management should instead focus on local hemostatic measures, supportive care, source control, transfusion support as needed, and the overall clinical context. This threshold does not exclude all bleeding risk, but it suggests that residual anticoagulant effect is less likely to be the main driver of bleeding.

30 to 50 ng/mL: Residual FXaI level may still be clinically relevant, but this range should be treated as a gray zone. In many patients, especially those without catastrophic bleeding, PCC may still be deferred. However, PCC can be considered when the clinical situation is especially high risk, such as life-threatening bleeding, bleeding at a critical site such as intracranial hemorrhage, or urgent surgery or intervention with very high bleeding risk that cannot be delayed. In this range, interpretation should be individualized and based on the severity of bleeding, the anatomic site, procedural urgency, and whether a specific reversal agent is available.

>50 ng/mL: Residual FXaI level is more likely to be clinically significant and more likely to be contributing meaningfully to impaired hemostasis. In patients with major or life-threatening bleeding, or those requiring urgent or emergency high bleeding risk surgery, this level would support consideration of PCC, particularly when a specific antidote is unavailable. For urgent procedural decision-making, the acceptable threshold may vary with the bleeding risk of the planned intervention, and some situations may justify use of a higher threshold in the 50 to 75 ng/mL range depending on surgical context.

Interpretive note: These thresholds should support, not replace, clinical judgment. Decisions about PCC should still be driven primarily by bleeding severity, bleeding site, procedural urgency, and whether definitive local hemostasis or delay to permit drug clearance is feasible. In general, 50 ng/mL is a reasonable threshold for considering reversal in major bleeding, whereas 30 ng/mL may be considered in particularly severe or life-threatening bleeding.

3 of 3

Major bleed on Edoxaban

  1. 1

    Determine the expected rate of drug clearance based on:

    Time elapsed since last Edoxaban dose:

    • —

    Patient’s creatinine clearance:

    • —
    • —

    And:

    CrCl ≥ 50 mL/ min

    Half-life is 10-14 hours

    Acute or worsening renal dysfunction

    Drug exposure may be increased and half-life may be prolonged, particularly with severe renal impairment. No reliable AKI-specific estimate is available.

  2. 2

    If clinically significant FXaI levels are likely to be present based on:

    • Age
    • Weight
    • Renal/hepatic function
    • Concurrent interacting medications
    • Time since last Edoxaban dose


    OR level is confirmed using a FXaI-specific assay (levels over 30 to 50ng/mL) - See Note

As directed by protocol

Protocol directs: Administer PCC

Dose

2000 units fixed dose or 25-50 units/kg, maximum single dose of 5000 IU

Safety

Contraindicated in patients with a history of heparin-induced thrombocytopenia

Note

PCC is not a specific reversal agent but the only available prohemostatic therapy

Consult local institutional protocols or hematology/thrombosis for advice as required and inform patients/ families regarding thrombotic risks.

Is management complete and bleeding resolved?

Rivaroxaban

Which laboratory tests are available?

  • PT/INR
  • aPTT
  • Heparin or LMWH anti-Xa
  • Calibrated FXaI level (anti-Xa assay with FXaI-specific calibrators)

When was the timing of the last DOAC dose?

Next

Creatinine clearance (mL/min)

Next

Last updated: 16-JUL-2026
Source
  • Thrombosis Canada, 2025
No PCC is approved in Canada for this indication; use is guideline-supported
1 of 3

Major bleed on Rivaroxaban

  1. 1

    Hold: DOAC therapy

  2. 2

    Initiate: resuscitation in a monitored setting

  3. 3

    Apply: local hemostatic measures if appropriate (i.e. compression, packing, suturing)

  4. 4

    Consult: an expert urgently for advice regarding management of coagulopathy (i.e. hematologist, internist, ER physician, pharmacist) and consult for definitive procedural intervention as applicable (i.e. gastroenterology, interventional radiology, surgery)

  5. 5

    STAT: laboratory testing for hemoglobin, platelet count, coagulation tests (PT/INR, aPTT), creatinine, liver function tests, group and screen (as appropriate)

As directed by protocol

Next

Disclaimer

DOAC-specific calibrated anti-Xa assays remain the preferred method for measuring direct factor Xa inhibitor concentrations. LMWH-calibrated anti-Xa assays should not be used interchangeably across centers or assumed to directly provide a DOAC level in ng/mL. Their performance is assay-, reagent-, analyzer-, and drug-specific, and the IU/mL output requires careful local validation before clinical use. Where a center uses an LMWH-calibrated anti-Xa assay as a surrogate for apixaban, rivaroxaban, or edoxaban measurement, the laboratory should provide assay-specific interpretive guidance, including locally validated cutoffs or approximate conversion ranges to clinically relevant DOAC concentrations, the reportable/roughly linear range, and important limitations. This approach should only be used when such local validation and reporting infrastructure are in place.

2 of 3

Major bleed on Rivaroxaban

  1. 1

    Measure: plasma concentration of DOAC using a specific validated assay (heparin or LMWH anti-Xa, FXaI-specific calibrated anti-Xa) if available with timely results AND the results would change management

    See disclaimer

  2. 2

    Determine: whether clinically significant levels of FXaI are likely to be present

As directed by protocol

PT/INR

PT/INR

IF

Normal

THEN
does NOT exclude a clinically significant FXaI level

IF

Increased

THEN
May indicate a clinically significant FXaI level

aPTT

aPTT

IF

Normal

THEN
Does NOT exclude a clinically significant FXaI level

IF

Increased

THEN
may indicate a clinically significant FXaI level

Heparin or LMWH anti-Xa

Heparin or LMWH anti Xa

IF

<0.1 IU/mL

THEN
likely no clinically significant FXaI level

IF

>0.1 IU/mL

THEN
possible clinically significant FXaI level

(assay dependent)

Calibrated FXaI level (anti-Xa assay with FXaI-specific calibrators)

Calibrated FXaI level

IF

<30 ng/mL

THEN
FXaI level is not significantly contributing to impaired hemostasis

IF

30-50ng/mL

THEN
FXaI level less likely to be significantly contributing to impaired hemostasis

IF

>50 ng/mL

THEN
FXaI level is likely to be significantly contributing to impaired hemostasis

Next

Note

<30 ng/mL: Residual FXaI level is unlikely to be a major contributor to ongoing impaired hemostasis. At this level, the DOAC effect alone would generally not justify PCC administration, and management should instead focus on local hemostatic measures, supportive care, source control, transfusion support as needed, and the overall clinical context. This threshold does not exclude all bleeding risk, but it suggests that residual anticoagulant effect is less likely to be the main driver of bleeding.

30 to 50 ng/mL: Residual FXaI level may still be clinically relevant, but this range should be treated as a gray zone. In many patients, especially those without catastrophic bleeding, PCC may still be deferred. However, PCC can be considered when the clinical situation is especially high risk, such as life-threatening bleeding, bleeding at a critical site such as intracranial hemorrhage, or urgent surgery or intervention with very high bleeding risk that cannot be delayed. In this range, interpretation should be individualized and based on the severity of bleeding, the anatomic site, procedural urgency, and whether a specific reversal agent is available.

>50 ng/mL: Residual FXaI level is more likely to be clinically significant and more likely to be contributing meaningfully to impaired hemostasis. In patients with major or life-threatening bleeding, or those requiring urgent or emergency high bleeding risk surgery, this level would support consideration of PCC, particularly when a specific antidote is unavailable. For urgent procedural decision-making, the acceptable threshold may vary with the bleeding risk of the planned intervention, and some situations may justify use of a higher threshold in the 50 to 75 ng/mL range depending on surgical context.

Interpretive note: These thresholds should support, not replace, clinical judgment. Decisions about PCC should still be driven primarily by bleeding severity, bleeding site, procedural urgency, and whether definitive local hemostasis or delay to permit drug clearance is feasible. In general, 50 ng/mL is a reasonable threshold for considering reversal in major bleeding, whereas 30 ng/mL may be considered in particularly severe or life-threatening bleeding.

3 of 3

Major bleed on Rivaroxaban

  1. 1

    Determine the expected rate of drug clearance based on:

    Time elapsed since last Rivaroxaban dose:

    • —

    Patient’s creatinine clearance:

    • —
    • —

    And:

    CrCl ≥ 50 mL/ min

    Half-life is 7-11 hours

    Acute or worsening renal dysfunction

    Drug exposure may be increased, although stable renal impairment causes only modest prolongation of the terminal half-life. No reliable AKI-specific estimate is available.

  2. 2

    If clinically significant FXaI levels are likely to be present based on:

    • Age
    • Weight
    • Renal/hepatic function
    • Concurrent interacting medications
    • Time since last Rivaroxaban dose


    OR level is confirmed using a FXaI-specific assay (levels over 30 to 50ng/mL) - See Note

As directed by protocol

Protocol Directs: Administer PCC

Dose

2000 units fixed dose or 25-50 units/kg, maximum single dose of 5000 IU

Safety

Contraindicated in patients with a history of heparin-induced thrombocytopenia

Note

PCC is not a specific reversal agent but the only available prohemostatic therapy

Consult local institutional protocols or hematology/thrombosis for advice as required and inform patients/ families regarding thrombotic risks.

Is management complete and bleeding resolved?

Dabigatran 

Which laboratory tests are available?

  • PT/INR
  • aPTT
  • Thrombin time
  • Dilute TT or Ecarin time

When was the timing of the last DOAC dose?

Next

Creatinine clearance (mL/min)

Next

Last updated: 16-JUL-2026
Source
  • Thrombosis Canada, 2025
No PCC is approved in Canada for this indication; use is guideline-supported
1 of 3

Major bleed on Dabigatran

  1. 1

    Hold: DOAC therapy

  2. 2

    Initiate: resuscitation in a monitored setting

  3. 3

    Apply: local hemostatic measures if appropriate (i.e. compression, packing, suturing)

  4. 4

    Consult: an expert urgently for advice regarding management of coagulopathy (i.e. hematologist, internist, ER physician, pharmacist) and consult for definitive procedural intervention as applicable (i.e. gastroenterology, interventional radiology, surgery)

  5. 5

    STAT: laboratory testing for hemoglobin, platelet count, coagulation tests (PT/INR, aPTT), creatinine, liver function tests, group and screen (as appropriate)

As directed by protocol

Next

2 of 3

Major bleed on Dabigatran

  1. 1

    Measure: plasma concentration of DOAC using a specific validated assay (Dilute TT OR ECT AND thrombin time) if available with timely results AND the results would change management

  2. 2

    Determine: whether clinically significant levels of Dabigatran are likely to be present

As directed by protocol

PT/INR

PT/INR

IF

Normal

THEN
does NOT exclude a clinically significant Dabigatran level

IF

Increased

THEN
May indicate a clinically significant Dabigatran level

aPTT

aPTT

IF

Normal

THEN
Does NOT exclude a clinically significant Dabigatran level

IF

Increased

THEN
may indicate a clinically significant Dabigatran level

Thrombin time

Thrombin time

IF

Normal

THEN
No Dabigatran present

IF

Increase

THEN
Some Dabigatran effect

Dilute TT or Ecarin time

Dilute TT or Ecarin time

IF

<30 ng/mL

THEN
Dabigatran level is not significantly contributing to impaired hemostasis

IF

30-50ng/mL

THEN
Dabigatran level less likely to be significantly contributing to impaired hemostasis

IF

>50 ng/mL

THEN
Dabigatran level is likely to be significantly contributing to impaired hemostasis

Next

Note

<30 ng/mL: Residual Dabigatran level is unlikely to be a major contributor to ongoing impaired hemostasis. At this level, the DOAC effect alone would generally not justify PCC administration, and management should instead focus on local hemostatic measures, supportive care, source control, transfusion support as needed, and the overall clinical context. This threshold does not exclude all bleeding risk, but it suggests that residual anticoagulant effect is less likely to be the main driver of bleeding.


30 to 50 ng/mL: Residual Dabigatran level may still be clinically relevant, but this range should be treated as a gray zone. In many patients, especially those without catastrophic bleeding, PCC may still be deferred. However, PCC can be considered when the clinical situation is especially high risk, such as life-threatening bleeding, bleeding at a critical site such as intracranial hemorrhage, or urgent surgery or intervention with very high bleeding risk that cannot be delayed. In this range, interpretation should be individualized and based on the severity of bleeding, the anatomic site, procedural urgency, and whether a specific reversal agent is available.


>50 ng/mL: Residual Dabigatran level is more likely to be clinically significant and more likely to be contributing meaningfully to impaired hemostasis. In patients with major or life-threatening bleeding, or those requiring urgent or emergency high bleeding risk surgery, this level would support consideration of PCC, particularly when a specific antidote is unavailable. For urgent procedural decision-making, the acceptable threshold may vary with the bleeding risk of the planned intervention, and some situations may justify use of a higher threshold in the 50 to 75 ng/mL range depending on surgical context.


Interpretive note: These thresholds should support, not replace, clinical judgment. Decisions about PCC should still be driven primarily by bleeding severity, bleeding site, procedural urgency, and whether definitive local hemostasis or delay to permit drug clearance is feasible. In general, 50 ng/mL is a reasonable threshold for considering reversal in major bleeding, whereas 30 ng/mL may be considered in particularly severe or life-threatening bleeding.

3 of 3

Major bleed on Dabigatran

  1. 1

    Determine the expected rate of drug clearance based on:

    Time elapsed since last Dabigatran dose:

    • —

    Patient’s creatinine clearance:

    • —
    • —

    And:

    CrCl >80 mL/min

    Half-life is 13.4 hours

    CrCl >50 to ≤80 mL/min

    Half-life is 15.3 hours

    CrCl >30 to ≤50 mL/min

    Half-life is 18.4 hours

    CrCl ≤30 mL/min

    Half-life is 27.2 hours

  2. 2

    If clinically significant Dabigatran levels are likely to be present based on:

    • Age
    • Weight
    • Renal/hepatic function
    • Concurrent interacting medications
    • Time since last Dabigatran dose


    OR level is confirmed using a specific assay (levels over 30 to 50ng/mL) - See Note

As directed by protocol

Protocol directs: Administer Idarucizumab

Specific reversal agent

Dose

5 g IV (2 x 2.5 g vials)

Hemodialysis can be considered as an adjunctive measure if inadequate response to Idarucizumab particularly in the setting of AKI

Note

aPCC may be used if PCC unavailable

Protocol directs: Administer PCC

If specific reversal is not available

Dose

2000 units fixed dose or 25-50 units/kg, maximum single dose of 5000 IU

Safety

Contraindicated in patients with a history of heparin-induced thrombocytopenia

Consult local institutional protocols or hematology/thrombosis for advice as required and inform patients/ families regarding thrombotic risks.

Is management complete and bleeding resolved?

Surgery on DOAC

Thombosis Canada perioperative anticoagulant algorithmhttps://thrombosiscanada.ca/hcp/practice/clinical_tools?calc=perioperativeAnticoagulantAlgorithm

Large/ academic hospital

What type of patient is being managed?

Pediatric patient

Last updated: 16-JUL-2026
SOURCE
  • MHP 2.0
  • ORBCoN MHP Toolkit, 2020
No PCC or FC is approved in Canada for this indication; use is guideline-supported
Step 1 of 3

Initial management 

  1. 1

    Identify source, attempt local control of hemorrhage, and engage definitive hemorrhage control staff (i.e. trauma surgeon/OR/IR)

  2. 2

    Obtain IV/IO access

  3. 3

    Consider TXA 30 mg/kg (max 2 g) and infusion of 10 mg/kg/hr IV/IO

  4. 4

    Measure temperature, prevent hypothermia and achieve normothermia (>36⁰C). 

  5. 5

    Complete laboratory testing at baseline and at a minimum hourly until the protocol is terminated. 


    I.e. CBC, PT/INR, aPTT, fibrinogen, electrolytes, calcium (ionized), arterial or venous blood gas (pH and base excess), lactate, blood glucose, group and screen (with initial labs)

  6. 6

    Transfuse all of “Cooler 1” (20 mL/kg per dose) BEFORE “Cooler 2”, UNLESS lab results direct otherwise

    Weight

    Cooler 1

    Cooler 2

    Cooler 3

    Cooler 4+

    > 40kg

    4U RBC

    4U RBC,

    4U Octaplasma

    4U RBC

    2U Octaplasma

    4g FC

    4U RBC

    2U Octaplasma

    31-40kg

    3U RBC

    3U RBC

    3U Octaplasma

    3U RBC

    2U Octaplasma

    2g FC

    3U RBC

    2U Octaplasma

    10-30kg

    2U RBC

    2U RBC

    2U Octaplasma

    2U RBC

    1U Octaplasma

    2g FC

    2U RBC

    1U Octaplasma

    <10kg

    1U RBC

    1U RBC

    1U Octaplasma

    1U RBC

    1U Octaplasma

    1g FC

    1U RBC

    1U Octaplasma

    For coolers 2+ adjust RBC: Plasma ratio 1-2:1 (weight-based dosing) as needed UNTIL lab directed dosing possible.


    Administer O Negative for females, otherwise O Positive RBC


    Laboratory guided transfusion once available and bleeding rate controlled

    If

    Then

    Hgb < 80g/L

    RBC 20mL/kg per dose

    (max 1 unit, ~287mL)

    INR ≥ 1.8

    Octaplasma 10-20mL/kg per dose

    Fibrinogen <1.5 g/L

    FC 50mg/kg, max 4g

    (max 2g if <30kg)

    Platelets < 50 x 10⁹/L

    Platelets 10 mL/kg per dose

  7. 7

    Limit use of crystalloids

  8. 8

    Administer calcium chloride 20 mg/kg (max 1g) or calcium gluconate 60 mg/kg IV (max 3g)

  9. 9

    Reverse anticoagulation if applicable

    Warfarin

    Vitamin K 1-10mg (neonate to adolescent) IV over 10 min & PCC 15IU/kg for INR <3 (or unknown) & 30IU/kg if INR ≥ 3 (max 2000 IU)

    Thrombin/ Factor Xa inhibitors or Heparins

    Consult with hematologist and/or call pharmacy for dosing

  10. 10

    Transfer for definitive bleeding control

As directed by protocol

Is initial management complete?

Yes

Step 2 of 3

Assessment every 30-60 minutes

  1. 1

    Can MHP be turned off? Can patient be switched to laboratory directed transfusion? Consider: bleeding controlled? Hemodynamics stable? 

  2. 2

    Is patient’s core temperature >36°C?

  3. 3

    Are blood samples collected q30-60 mins? Is the transfusion of products adjusted?

  4. 4

    Administer calcium chloride 20 mg/kg (max 1 g) or gluconate 60 mg/Kg IV (max 3 g) after each RBC equivalent of one cooler (or up to a maximum of 4U RBC) transfused or ionized calcium <1.15 mmol/L

  5. 5

    Monitor for complications (ex. hyperkalemia, hypothermia and volume overload)

  6. 6

    Is resuscitation adequate? (ex. hemodynamics, lactate, base deficit, account for traumatic brain injury)

  7. 7

    Switch to group specific blood products when possible

As directed by protocol

Can the MHP be deactivated?

Yes

Step 3 of 3

Termination

  1. 1

    Deactivate MHP as per local policy 

  2. 2

    Perform bedside termination checklist

  3. 3

    Inform family member and SDM of needing MHP

  4. 4

    Ensure coolers and unused MHP components are returned to transfusion medicine lab ASAP 

  5. 5

    Complete documentation and hand-over 

As directed by protocol

Scenario complete

Reset to start over or to select another scenario

AcknowledgmentsAdapted from ORBCON's MHP Toolkit and MHP 2.0 guidelines with clinical oversight by Dr. Brodie Nolan

Adult patient

Does the uncontrolled severe bleeding arise in the course of a surgical intervention (e.g., caesarean section, intra-operative)?

Yes

Is the coagulopathy attributable to a vitamin K antagonist (e.g., warfarin) requiring rapid reversal or bleeding in cardiac surgery?

Yes

Last updated: 16-JUL-2026
SOURCE
  • MHP 2.0, 2025
  • ORBCoN MHP Toolkit, 2020
  • Fibryga PM, 2025
  • Octaplex PM, 2026
Fibryga and Octaplex are approved in Canada for this use
Step 1 of 3

Initial management 

  1. 1

    Identify source, attempt local control of hemorrhage, and engage definitive hemorrhage control staff (i.e. trauma surgeon/OR/IR)

  2. 2

    Obtain IV/IO access

  3. 3

    Consider TXA total dose of 2g IV/IO

  4. 4

    Measure temperature, prevent hypothermia and achieve normothermia (>36⁰C). 

  5. 5

    Complete laboratory testing at baseline and at a minimum hourly until the protocol is terminated. 


    I.e. CBC, PT/INR, aPTT, fibrinogen, electrolytes, calcium (ionized), arterial or venous blood gas (pH and base excess), lactate, blood glucose, group and screen (with initial labs). 

  6. 6

    Transfuse 1U RBC with rapid infuser as needed for blood pressure or hemoglobin targets

    Cooler 1

    4U RBC

    Cooler 2

    4U RBC

    4U Octaplasma

    Cooler 3

    4U RBC

    2U Octaplasma

    Cooler 4+

    4U RBC

    2U Octaplasma

    Administer O Negative RBC for females <45, otherwise O Positive RBC


    *At centers without available fibrinogen testing: the clinician may administer Fibryga based on clinical evidence of microvascular coagulopathy (e.g. oozing from IV sites) or profound hemodynamic instability where hypofibrinogenemia is predicted.


    Platelets and Fibryga should be transfused based on hourly laboratory test results.


    Laboratory guided transfusion once available and bleeding rate controlled

    If

    Then

    Hgb < 80 g/L

    RBC 2U

    INR ≥ 1.8

    Octaplasma 4U

    Fibrinogen < 1.5 g/L*

    Fibryga 4g

    Platelets < 50 x 10⁹/L

    Platelets 1 adult dose

    Ionized calcium <1.15 mmol/L

    Calcium chloride 1g or Calcium gluconate 3g

    *Less than 2.0 for post-partum hemorrhage


    ROTEM triggers if available

    If

    Then

    EXTEM CT > 80

    Octaplasma 4U

    EXTEM A10 < 35

    Platelets 1 adult dose

    FIBTEM A10 < 8-10

    Fibryga 4g

  7. 7

    Limit use of crystalloids

  8. 8

    Calcium chloride 1g IV

  9. 9

    Reverse anticoagulation if applicable

    Warfarin

    Octaplex 2000 IU IV over 10 min

    Vitamin K 10mg IV over 10 min

    Dabigatran

    Idarucizumab 5g IV over 10 min

    If unavailable, PCC 2000 IU IV over 10 mins

    Apixaban

    Rivaroxaban

    Edoxaban

    PCC 2000 IU IV over 10 min

    Repeat in 1 hour if bleeding continues

    Heparins

    Call pharmacy for protamine dosing

  10. 10

    Transfer for definitive bleeding control

Is initial management complete?

Yes

Step 2 of 3

Assessment every 30-60 minutes

  1. 1

    Can MHP be turned off? Can patient be switched to laboratory directed transfusion? Consider: bleeding controlled? Hemodynamics stable? 

  2. 2

    Is the next cooler needed? 

  3. 3

    Is patient’s core temperature >36°C?

  4. 4

    Are blood samples collected q30-60 mins? Is the transfusion of products adjusted?

  5. 5

    Administer calcium chloride 1g IV for every 4 RBC or ionized calcium < 1.15L

  6. 6

    Monitor for complications (ex. hyperkalemia, hypothermia and volume overload)

  7. 7

    Is resuscitation adequate? (ex. hemodynamics, lactate, base deficit, account for traumatic brain injury)

  8. 8

    Switch to group specific blood products when able

As directed by protocol

Can the MHP be deactivated?

Yes

Step 3 of 3

Termination: 

  1. 1

    Deactivate MHP as per local policy 

  2. 2

    Perform bedside termination checklist 

  3. 3

    Inform family member and SDM of needing MHP

  4. 4

    Ensure coolers and unused MHP components are returned to transfusion medicine lab ASAP 

  5. 5

    Complete documentation and hand-over

As directed by protocol

Scenario complete

Reset to start over or to select another scenario

AcknowledgmentsAdapted from ORBCON's MHP Toolkit and MHP 2.0 guidelines with clinical oversight by Dr. Brodie Nolan

No

Last updated: 16-JUL-2026
Source
  • MHP 2.0, 2025
  • ORBCoN MHP Toolkit, 2020
  • Fibryga PM, 2025
Fibryga is approved in Canada for this use
NOTENo PCC is approved in Canada for this indication; use is guideline-supported
Step 1 of 3

Initial management 

  1. 1

    Identify source, attempt local control of hemorrhage, and engage definitive hemorrhage control staff (i.e. trauma surgeon/OR/IR)

  2. 2

    Obtain IV/IO access

  3. 3

    Consider TXA total dose of 2g IV/IO

  4. 4

    Measure temperature, prevent hypothermia and achieve normothermia (>36⁰C). 

  5. 5

    Complete laboratory testing at baseline and at a minimum hourly until the protocol is terminated. 


    I.e. CBC, PT/INR, aPTT, fibrinogen, electrolytes, calcium (ionized), arterial or venous blood gas (pH and base excess), lactate, blood glucose, group and screen (with initial labs). 

  6. 6

    Transfuse 1U RBC with rapid infuser as needed for blood pressure or hemoglobin targets

    Cooler 1

    4U RBC

    Cooler 2

    4U RBC

    4U Octaplasma

    Cooler 3

    4U RBC

    2U Octaplasma

    Cooler 4+

    4U RBC

    2U Octaplasma

    Administer O Negative RBC for females <45, otherwise O Positive RBC


    *At centers without available fibrinogen testing: the clinician may administer Fibryga based on clinical evidence of microvascular coagulopathy (e.g. oozing from IV sites) or profound hemodynamic instability where hypofibrinogenemia is predicted.


    Platelets and Fibryga should be transfused based on hourly laboratory test results.


    Laboratory guided transfusion once available and bleeding rate controlled

    If

    Then

    Hgb < 80 g/L

    RBC 2U

    INR ≥ 1.8

    Octaplasma 4U

    Fibrinogen < 1.5 g/L*

    Fibryga 4g

    Platelets < 50 x 10⁹/L

    Platelets 1 adult dose

    Ionized calcium <1.15 mmol/L

    Calcium chloride 1g or Calcium gluconate 3g

    *Less than 2.0 for post-partum hemorrhage


    ROTEM triggers if available

    If

    Then

    EXTEM CT > 80

    Octaplasma 4U

    EXTEM A10 < 35

    Platelets 1 adult dose

    FIBTEM A10 < 8-10

    Fibryga 4g

  7. 7

    Limit use of crystalloids

  8. 8

    Calcium chloride 1g IV

  9. 9

    Reverse anticoagulation if applicable

    Dabigatran

    Idarucizumab 5g IV over 10 min

    If unavailable, PCC 2000 IU IV over 10 mins

    Apixaban

    Rivaroxaban

    Edoxaban

    PCC 2000 IU IV over 10 min

    Repeat in 1 hour if bleeding continues

    Heparins

    Call pharmacy for protamine dosing

  10. 10

    Transfer for definitive bleeding control

As directed by protocol

Is initial management complete?

No

Is the coagulopathy attributable to a vitamin K antagonist (e.g., warfarin) requiring rapid reversal or bleeding in cardiac surgery?

Yes

Last updated: 16-JUL-2026
Source
  • MHP 2.0, 2025
  • ORBCoN MHP Toolkit, 2020
  • Octaplex PM, 2026
Octaplex is approved in Canada for this use
No FC is approved in Canada for this indication; use is guideline-supported
Step 1 of 3

Initial management 

  1. 1

    Identify source, attempt local control of hemorrhage, and engage definitive hemorrhage control staff (i.e. trauma surgeon/OR/IR)

  2. 2

    Obtain IV/IO access

  3. 3

    Consider TXA total dose of 2g IV/IO

  4. 4

    Measure temperature, prevent hypothermia and achieve normothermia (>36⁰C). 

  5. 5

    Complete laboratory testing at baseline and at a minimum hourly until the protocol is terminated. 


    I.e. CBC, PT/INR, aPTT, fibrinogen, electrolytes, calcium (ionized), arterial or venous blood gas (pH and base excess), lactate, blood glucose, group and screen (with initial labs). 

  6. 6

    Transfuse 1U RBC with rapid infuser as needed for blood pressure or hemoglobin targets

    Cooler 1

    4U RBC

    Cooler 2

    4U RBC

    4U Octaplasma

    Cooler 3

    4U RBC

    2U Octaplasma

    Cooler 4+

    4U RBC

    2U Octaplasma

    Administer O Negative RBC for females <45, otherwise O Positive RBC


    *At centers without available fibrinogen testing: the clinician may administer Fibrinogen based on clinical evidence of microvascular coagulopathy (e.g. oozing from IV sites) or profound hemodynamic instability where hypofibrinogenemia is predicted.


    Platelets and Fibrinogen should be transfused based on hourly laboratory test results.


    Laboratory guided transfusion once available and bleeding rate controlled

    If

    Then

    Hgb < 80 g/L

    RBC 2U

    INR ≥ 1.8

    Octaplasma 4u

    Fibrinogen < 1.5 g/L*

    FC 4g

    Platelets < 50 x 10⁹/L

    Platelets 1 adult dose

    Ionized calcium <1.15 mmol/L

    Calcium chloride 1g or Calcium gluconate 3g

    *Less than 2.0 for post-partum hemorrhage


    ROTEM triggers if available

    If

    Then

    EXTEM CT > 80

    Octaplasma 4U

    EXTEM A10 < 35

    Platelets 1 adult dose

    FIBTEM A10 < 8-10

    FC 4g

  7. 7

    Limit use of crystalloids

  8. 8

    Calcium chloride 1g IV

  9. 9

    Reverse anticoagulation if applicable

    Warfarin

    Octaplex 2000 IU IV over 10 min

    Vitamin K 10mg IV over 10 min

    Dabigatran

    Idarucizumab 5g IV over 10 min

    If unavailable, PCC 2000 IU IV over 10 mins

    Apixaban

    Rivaroxaban

    Edoxaban

    PCC 2000 IU IV over 10 min

    Repeat in 1 hour if bleeding continues

    Heparins

    Call pharmacy for protamine dosing

  10. 10

    Transfer for definitive bleeding control

As directed by protocol

Is initial management complete?

No

Last updated: 16-JUL-2026
source
  • MHP 2.0, 2025
  • ORBCoN MHP Toolkit, 2020
No PCC or FC is approved in Canada for this indication; use is guideline-supported
Step 1 of 3

Initial management 

  1. 1

    Identify source, attempt local control of hemorrhage, and engage definitive hemorrhage control staff (i.e. trauma surgeon/OR/IR)

  2. 2

    Obtain IV/IO access

  3. 3

    Consider TXA total dose of 2g IV/IO

  4. 4

    Measure temperature, prevent hypothermia and achieve normothermia (>36⁰C). 

  5. 5

    Complete laboratory testing at baseline and at a minimum hourly until the protocol is terminated. 


    I.e. CBC, PT/INR, aPTT, fibrinogen, electrolytes, calcium (ionized), arterial or venous blood gas (pH and base excess), lactate, blood glucose, group and screen (with initial labs).

  6. 6

    Transfuse 1U RBC with rapid infuser as needed for blood pressure or hemoglobin targets

    Cooler 1

    4U RBC

    Cooler 2

    4U RBC

    4U Octaplasma

    Cooler 3

    4U RBC

    2U Octaplasma

    Cooler 4+

    4U RBC

    2U Octaplasma

    Administer O Negative RBC for females <45, otherwise O Positive RBC


    *At centers without available fibrinogen testing: the clinician may administer Fibrinogen based on clinical evidence of microvascular coagulopathy (e.g. oozing from IV sites) or profound hemodynamic instability where hypofibrinogenemia is predicted.


    Platelets and Fibrinogen should be transfused based on hourly laboratory test results.


    Laboratory guided transfusion once available and bleeding rate controlled

    If

    Then

    Hgb < 80 g/L

    RBC 2U

    INR ≥ 1.8

    Octaplasma 4u

    Fibrinogen < 1.5 g/L*

    FC 4g

    Platelets < 50 x 10⁹/L

    Platelets 1 adult dose

    Ionized calcium <1.15 mmol/L

    Calcium chloride 1g or Calcium gluconate 3g

    *Less than 2.0 for post-partum hemorrhage


    ROTEM triggers if available

    If

    Then

    EXTEM CT > 80

    Octaplasma 4U

    EXTEM A10 < 35

    Platelets 1 adult dose

    FIBTEM A10 < 8-10

    FC 4g

  7. 7

    Limit use of crystalloids

  8. 8

    Calcium chloride 1g IV

  9. 9

    Reverse anticoagulation if applicable

    Dabigatran

    Idarucizumab 5g IV over 10 min

    If unavailable, PCC 2000 IU IV over 10 mins

    Apixaban

    Rivaroxaban

    Edoxaban

    PCC 2000 IU IV over 10 min

    Repeat in 1 hour if bleeding continues

    Heparins

    Call pharmacy for protamine dosing

  10. 10

    Transfer for definitive bleeding control

As directed by protocol

Is initial management complete?

Community/ smaller hospital setting that cannot provide plasma

What type of patient is being managed?

Pediatric patient

Last updated: 16-JUL-2026
  • MHP 2.0
  • ORBCoN MHP Toolkit, 2020
No PCC or FC is approved in Canada for this indication; use is guideline-supported
Step 1 of 3

Initial management 

  1. 1

    Call for early transfer to pediatric trauma hospital and engage appropriate transport service

  2. 2

    Identify source and attempt local control of hemorrhage

  3. 3

    Obtain IV/IO access

  4. 4

    Consider TXA 30 mg/kg (max 2 g) and infusion of 10 mg/kg/hr IV/IO

  5. 5

    Measure temperature, prevent hypothermia and achieve normothermia (>36⁰C). 

  6. 6

    Complete laboratory testing at baseline and at a minimum hourly until the protocol is terminated. 


    I.e. CBC, PT/INR, aPTT, fibrinogen, electrolytes, calcium (ionized), arterial or venous blood gas (pH and base excess), lactate, blood glucose, group and screen (with initial labs). 

  7. 7

    Transfuse all of “Cooler 1” RBCs (20 ml/Kg per dose) BEFORE “Cooler 2” UNLESS lab results direct otherwise 

    Weight

    Cooler 1

    Cooler 2+

    > 40kg

    4U RBC

    4U RBC, 2000 IU PCC, 4g FC

    31-40kg

    3U RBC

    3U RBC, 1000 IU PCC, 2g FC

    10-30kg

    2U RBC

    2U RBC, 1000 IU PCC, 2g FC

    <10kg

    1U RBC

    1U RBC, 500 IU PCC, 1g FC

    Administer O Negative for females, otherwise O Positive RBC


    Fibrinogen should be given concurrently with PCC unless the fibrinogen level is known to be >1.5 g/L


    Laboratory guided transfusion once available and bleeding rate controlled

    If

    Then

    Hgb < 80g/L

    RBC 20mL/kg per dose

    (max 1 unit, ~287mL)

    INR ≥ 1.8

    PCC 25 IU/kg (rounded to closest 500 IU), max 2000 IU

    Fibrinogen <1.5 g/L

    FC 50mg/kg, max 4g (max 2g if <30kg)

    Platelets < 50 x 10⁹/L

    Platelets 10 mL/kg per dose

  8. 8

    Limit use of crystalloids

  9. 9

    Administer calcium chloride 20 mg/kg (max 1g) or calcium gluconate 60 mg/kg IV (max 3g)

  10. 10

    Reverse anticoagulation if applicable

    Warfarin

    Vitamin K 1-10mg (neonate to adolescent) IV over 10 min & PCC 15IU/kg for INR <3 (or unknown) & 30IU/kg if INR ≥ 3 (max 2000 IU)

    Thrombin/ Factor Xa inhibitors or Heparins

    Consult with hematologist and/or call pharmacy for dosing

  11. 11

    Transfer for definitive bleeding control

As directed by protocol

Is initial management complete?

Yes

Step 2 of 3

Assessment every 30-60 minutes

  1. 1

    Can MHP be turned off? Can patient be switched to laboratory directed transfusion? Consider: bleeding controlled? Hemodynamics stable? 

  2. 2

    Is patient’s core temperature >36°C?

  3. 3

    Are blood samples collected q30-60 mins? Is the transfusion of products adjusted?

  4. 4

    Administer calcium chloride 20 mg/kg (max 1 g) or gluconate 60 mg/Kg IV (max 3 g) after each RBC equivalent of one cooler (or up to a maximum of 4U RBC) transfused or ionized calcium <1.15 mmol/L

  5. 5

    Monitor for complications (ex. hyperkalemia, hypothermia and volume overload)

  6. 6

    Is resuscitation adequate? (ex. hemodynamics, lactate, base deficit, account for traumatic brain injury)

  7. 7

    Switch to group specific blood products when able

As directed by protocol

Can the MHP be deactivated?

Yes

Step 3 of 3

Termination

  1. 1

    Deactivate MHP as per local policy 

  2. 2

    Perform bedside termination checklist

  3. 3

    Inform family member and SDM of needing MHP

  4. 4

    Ensure coolers and unused MHP components are returned to transfusion medicine lab ASAP 

  5. 5

    Complete documentation and hand-over 

As directed by protocol

Scenario complete

Reset to start over or to select another scenario

Acknowledgements Adapted from ORBCON's MHP Toolkit and MHP 2.0 guidelines with clinical oversight by Dr. Brodie Nolan

Adult patient

Does the uncontrolled severe bleeding arise in the course of a surgical intervention (e.g., caesarean section, intra-operative)?

Yes

Is the coagulopathy attributable to a vitamin K antagonist (e.g., warfarin) requiring rapid reversal or bleeding in cardiac surgery?

Yes

Last updated: 16-JUL-2026
Source
  • MHP 2.0, 2025
  • ORBCoN MHP Toolkit, 2020
  • Fibryga PM, 2025
  • Octaplex PM, 2026
Fibryga and Octaplex are approved in Canada for this use
Step 1 of 3

Initial management 

  1. 1

    Call for early transfer to tertiary care center and engage appropriate transport service

  2. 2

    Identify source and attempt local control of hemorrhage

  3. 3

    Obtain IV/IO access

  4. 4

    Consider TXA total dose of 2g IV/IO

  5. 5

    Measure temperature, prevent hypothermia and achieve normothermia (>36⁰C). 

  6. 6

    Complete laboratory testing at baseline and at a minimum hourly until the protocol is terminated. 


    I.e. CBC, PT/INR, aPTT, fibrinogen, electrolytes, calcium (ionized), arterial or venous blood gas (pH and base excess), lactate, blood glucose, group and screen (with initial labs). 

  7. 7

    Transfuse 1U RBC with rapid infuser as needed for blood pressure or hemoglobin targets

    Cooler 1

    4U RBC

    Cooler 2+

    4U RBC

    2000 IU Octaplex

    4g Fibryga

    Administer O Negative RBC for females <45, otherwise O Positive RBC


    Fibryga should be given concurrently with Octaplex unless the fibrinogen level is known to be >1.5g/L


    Laboratory guided transfusion once available and bleeding rate controlled

    If

    Then

    Hgb < 80 g/L

    RBC 2U

    INR ≥ 1.8

    Octaplasma 4U

    Fibrinogen < 1.5 g/L*

    Fibryga 4g

    Platelets < 50 x 10⁹/L

    Platelets 1 adult dose

    Ionized calcium < 1.15 mmol/L

    Calcium chloride 1g or Calcium gluconate 3g IV

    *Less than 2.0 for post-partum hemorrhage

  8. 8

    Limit use of crystalloids

  9. 9

    Calcium chloride 1g IV

  10. 10

    Reverse anticoagulation if applicable

    Warfarin

    Octaplex 2000 IU IV over 10 min

    Vitamin K 10mg IV over 10 min

    Dabigatran

    Idarucizumab 5g IV over 10 min

    If unavailable, PCC 2000 IU IV over 10 mins

    Apixaban

    Rivaroxaban

    Edoxaban

    PCC 2000 IU IV over 10 mins

    Repeat in 1 hour if bleeding continues

    Heparins

    Call pharmacy for protamine dosing

  11. 11

    Transfer patient via EMS/ critical care ambulance for definitive bleeding control

As directed by protocol

Is initial management complete?

yes

Step 2 of 3

Assessment every 30-60 minutes

  1. 1

    Can MHP be turned off? Can patient be switched to laboratory directed transfusion? Consider: bleeding controlled? Hemodynamics stable? 

  2. 2

    Is the next cooler needed? 

  3. 3

    Is patient’s core temperature >36°C?

  4. 4

    Are blood samples collected q30-60 mins? Is the transfusion of products adjusted?

  5. 5

    Administer calcium chloride 1g IV for every 4 RBC or ionized calcium < 1.15L

  6. 6

    Monitor for complications (ex. hyperkalemia, hypothermia and volume overload)

  7. 7

    Is resuscitation adequate? (ex. hemodynamics, lactate, base deficit, account for traumatic brain injury)

  8. 8

    Switch to group specific blood products when able

As directed by protocol

Can the MHP be deactivated?

Yes

Step 3 of 3

Termination: 

  1. 1

    Deactivate MHP as per local policy 

  2. 2

    Perform bedside termination checklist 

  3. 3

    Inform family member and SDM of needing MHP

  4. 4

    Ensure coolers and unused MHP components are returned to transfusion medicine lab ASAP 

  5. 5

    Complete documentation and hand-over

As directed by protocol

Scenario complete

Reset to start over or to select another scenario

AcknowledgmentsAdapted from ORBCON's MHP Toolkit and MHP 2.0 guidelines with clinical oversight by Dr. Brodie Nolan

No

Last updated: 16-JUL-2026
SOURCE
  • MHP 2.0, 2025
  • ORBCoN MHP Toolkit, 2020
  • Fibryga PM, 2025
Fibryga is approved in Canada for this use
No PCC is approved in Canada for this indication; use is guideline-supported
Step 1 of 3

Initial management 

  1. 1

    Call for early transfer to tertiary care center and engage appropriate transport service

  2. 2

    Identify source and attempt local control of hemorrhage

  3. 3

    Obtain IV/IO access

  4. 4

    Consider TXA total dose of 2g IV/IO

  5. 5

    Measure temperature, prevent hypothermia and achieve normothermia (>36⁰C). 

  6. 6

    Complete laboratory testing at baseline and at a minimum hourly until the protocol is terminated. 


    I.e. CBC, PT/INR, aPTT, fibrinogen, electrolytes, calcium (ionized), arterial or venous blood gas (pH and base excess), lactate, blood glucose, group and screen (with initial labs). 

  7. 7

    Transfuse 4U RBC with rapid infuser

    Cooler 1

    4U RBC

    Cooler 2+

    4U RBC 4U

    2000 IU PCC

    4g Fibryga

    Administer O Negative RBC for females <45, otherwise O Positive RBC


    Fibryga should be given concurrently with PCC unless the fibrinogen level is known to be >1.5g/L


    Laboratory guided transfusion once available and bleeding rate controlled

    If

    Then

    Hgb < 80 g/L

    RBC 2U

    INR ≥ 1.8

    Octaplasma 4U

    Fibrinogen < 1.5 g/L*

    Fibryga 4g

    Platelets < 50 x 10⁹/L

    Platelets 1 adult dose

    Ionized calcium <1.15 mmol/L

    Calcium chloride 1g or Calcium gluconate 3g IV

    *Less than 2.0 for post-partum hemorrhage

  8. 8

    Limit use of crystalloids

  9. 9

    Calcium chloride 1g IV

  10. 10

    Reverse anticoagulation if applicable

    Dabigatran

    Idarucizumab 5g IV over 10 min

    If unavailable, PCC 2000 IU IV over 10 mins

    Apixaban

    Rivaroxaban

    Edoxaban

    PCC 2000 IU IV over 10 mins

    Repeat in 1 hour if bleeding continues

    Heparins

    Call pharmacy for protamine dosing

  11. 11

    Transfer patient via EMS/ critical care ambulance for definitive bleeding control

As directed by protocol

Is initial management complete?

No

Is the coagulopathy attributable to a vitamin K antagonist (e.g., warfarin) requiring rapid reversal or bleeding in cardiac surgery?

Yes

Last updated: 16-JUL-2026
SOURCE
  • MHP 2.0, 2025
  • ORBCoN MHP Toolkit, 2020
  • Octaplex PM, 2026
Octaplex is approved in Canada for this use
NOTENo FC is approved in Canada for this indication; use is guideline-supported
Step 1 of 3

Initial management 

  1. 1

    Call for early transfer to tertiary care center 

  2. 2

    Identify source and attempt local control of hemorrhage and engage appropriate transport service

  3. 3

    Obtain IV/IO access

  4. 4

    Consider TXA total dose of 2g IV/IO

  5. 5

    Measure temperature, prevent hypothermia and achieve normothermia (>36⁰C). 

  6. 6

    Complete laboratory testing at baseline and at a minimum hourly until the protocol is terminated. 


    I.e. CBC, PT/INR, aPTT, fibrinogen, electrolytes, calcium (ionized), arterial or venous blood gas (pH and base excess), lactate, blood glucose, group and screen (with initial labs). 

  7. 7

    Transfuse 4U RBC with rapid infuser

    Cooler 1

    4U RBC

    Cooler 2+

    4U RBC 4U

    2000 IU Octaplex

    4g FC

    Administer O Negative RBC for females <45, otherwise O Positive RBC


    Fibrinogen should be given concurrently with Octaplex unless the fibrinogen level is known to be >1.5g/L


    Laboratory guided transfusion once available and bleeding rate controlled

    If

    Then

    Hgb < 80 g/L

    RBC 2U

    INR ≥ 1.8

    Octaplasma 4U

    Fibrinogen < 1.5 g/L*

    FC 4g

    Platelets < 50 x 10⁹/L

    Platelets 1 adult dose

    Ionized calcium <1.15 mmol/L

    Calcium chloride 1g or Calcium gluconate 3g IV

    *Less than 2.0 for post-partum hemorrhage

  8. 8

    Limit use of crystalloids

  9. 9

    Calcium chloride 1g IV

  10. 10

    Reverse anticoagulation if applicable

    Warfarin

    Octaplex 2000 IU IV over 10 min

    Vitamin K 10mg IV over 10 min

    Dabigatran

    Idarucizumab 5g IV over 10 min

    If unavailable, PCC 2000 IU IV over 10 mins

    Apixaban

    Rivaroxaban

    Edoxaban

    PCC 2000 IU IV over 10 mins

    Repeat in 1 hour if bleeding continues

    Heparins

    Call pharmacy for protamine dosing

  11. 11

    Transfer patient via EMS/ critical care ambulance for definitive bleeding control

As directed by protocol

Is initial management complete?

No

Last updated: 16-JUL-2026
source
  • MHP 2.0, 2025
  • ORBCoN MHP Toolkit, 2020
No PCC or FC is approved in Canada for this indication; use is guideline-supported
Step 1 of 3

Initial management 

  1. 1

    Call for early transfer to tertiary care center and engaged appropriate transport service

  2. 2

    Identify source and attempt local control of hemorrhage

  3. 3

    Obtain IV/IO access

  4. 4

    Consider TXA total dose of 2g IV/IO

  5. 5

    Measure temperature, prevent hypothermia and achieve normothermia (>36⁰C). 

  6. 6

    Complete laboratory testing at baseline and at a minimum hourly until the protocol is terminated. 


    I.e. CBC, PT/INR, aPTT, fibrinogen, electrolytes, calcium (ionized), arterial or venous blood gas (pH and base excess), lactate, blood glucose, group and screen (with initial labs). 

  7. 7

    Transfuse 4U RBC with rapid infuser

    Cooler 1

    4U RBC

    Cooler 2+

    4U RBC

    2000 IU PCC

    4g FC

    Administer O Negative RBC for females <45, otherwise O Positive RBC


    Fibrinogen should be given concurrently with PCC unless the fibrinogen level is known to be >1.5g/L


    Laboratory guided transfusion once available and bleeding rate controlled

    If

    Then

    Hgb < 80 g/L

    RBC 2U

    INR ≥ 1.8

    Octaplasma 4U

    Fibrinogen < 1.5 g/L*

    FC 4g

    Platelets < 50 x 10⁹/L

    Platelets 1 adult dose

    Ionized calcium <1.15 mmol/L

    Calcium chloride 1g or Calcium gluconate 3g IV

    *Less than 2.0 for post-partum hemorrhage

  8. 8

    Limit use of crystalloids

  9. 9

    Calcium chloride 1g IV

  10. 10

    Reverse anticoagulation if applicable

    Dabigatran

    Idarucizumab 5g IV over 10 min

    If unavailable, PCC 2000 IU IV over 10 mins

    Apixaban

    Rivaroxaban

    Edoxaban

    PCC 2000 IU IV over 10 mins

    Repeat in 1 hour if bleeding continues

    Heparins

    Call pharmacy for protamine dosing

  11. 11

    Transfer patient via EMS/ critical care ambulance for definitive bleeding control

As directed by protocol

Is initial management complete?

Cardiac Surgery

This is a scenario-based simulator. No patient information should be entered, and the tool does not record what you enter.

What is the situation?

Preparing for a bleed 

Last updated: 16-JUL-2026
SOURCE
  • TGH algorithm
Step 1 of 3

PATIENT COMING OFF BYPASS

  1. 1

    Measure CBC

  2. 2

    If CPB duration is >150 minutes, measure ROTEM/TEG/ INR (based on available testing)

Step 2 of 3

AFTER COMING OFF BYPASS

  1. 1

    Administer Protamine when appropriate to reverse Heparin at <1mg per 100 U of the initial heparin dose  

  2. 2

    If ACT is not normalized ± 10% of baseline, administer additional protamine 

  3. 3

    Optimize temperature (>36°C), pH (>7.2), iCa (>1.0 mmol/L) and Hgb (>75 g/L)

  4. 4

    Continue antifibrinolytics

Step 3 of 3

ASSESS BLEEDING SEVERITY SCORE (BSS)

  1. 1

    If BSS < 2 no action

  2. 2

    If BSS ≥ 2, measure ROTEM/ TEG/ INR (based on available testing) if was not measured or was normal at re-warming 

As directed by protocol
Grade 2 bleeding (video 3)https://www.surgjournal.com/article/S0039-6060(16)30605-5/fulltext

What is the bleeding severity score?

BSS < 2

No transfusion required

Scenario complete

Reset to start over or to select another scenario

AcknowledgementsAdapted from Toronto General Hospital's cardiac surgery bleed management protocol with clinical oversight by Dr. Keyvan Karkouti.

BSS ≥ 2

What point-of-care testing is available?

ROTEM

Last updated: 16-JUL-2026
Source
  • FARES-II, 2025
  • FIBRES, 2019
  • TGH Algorithm
  • SCA, 2019
  • Octaplex PM, 2026
  • Fibryga PM, 2025
Fibryga and Octaplex are approved in Canada for this use

ROTEM thresholds

As directed by protocol

If

[HEPTEM CT/ INTEM CT] <0.9

Administer
Protamine

10-50 mg prn   

If

A10-FIBTEM ≤ 10mm 

Administer

4g, re-dose as needed 

If

CT-EXTEM > 100s

Administer

1500 IU if IBW < 60kg and 2000 IU if IBW ≥ 60kg. Not recommended if HIT is present. Re-dose only once, then use Octaplasma if needed..

If

A10-EXTEM < 40 mm and A10-FIBTEM > 10mm

Administer
Platelets

1 adult dose, re-dose as needed  

If

INTEM or EXTEM ML > 7% at 30 min or >15% at 60 min 

Administer
Aminocaproic Acid or Tranexamic Acid 

Dose and re-dose according to what has been administered.

If

Hgb <80 g/L

Administer
RBC

One unit at a time, followed by clinical reassessment 

ALWAYS

Check and optimize

  1. 1

    Temperature >36 °C

  2. 2

    pH > 7.2

  3. 3

    iCa > 1.0 mmol/L

  4. 4

    Hgb > 75 g/L

If excessive bleeding persists despite normal ROTEM, consider surgical re-exploration

Is transfusion complete and bleeding stabilized?

Yes

Repeat routine lab assays (i.e. CBC/ PT/ PTT/ INR/ Fibrinogen)

Management

IF

Patient is stable, Hgb < 80 g/L 

THEN
Monitor and evaluate volume status. Consider administering one RBC unit at a time followed by clinical reassessment if appropriate 

IF

If patient is unstable, Hgb < 90g/L

THEN
Administer one RBC unit at a time followed by clinical reassessment

Scenario complete

Reset to start over or to select another scenario

AcknowledgmentsAdapted from the Society of Cardiovascular Anesthesiologists' "Clinical Practice Improvement Advisory for Management of Perioperative Bleeding and Hemostasis in Cardiac Surgery Patients" and Toronto General Hospital's cardiac surgery bleed management protocol with clinical oversight by Dr. Keyvan Karkouti.

TEG 5000

Last updated: 16-JUL-2026
SOURCE
  • FARES-II, 2025
  • FIBRES, 2019
  • SCA, 2019
  • Octaplex PM, 2026
  • Fibryga PM, 2025
Fibryga and Octaplex are approved in Canada for this use

TEG 5000 thresholds

As directed by protocol

If

TEG R > hTEG R x 1.25 

Administer
Protamine

at 10-50 mg prn   

If

MA < 40 mm and FF > 8 mm 

Administer

4g, re-dose as needed

If

Hteg R > 12 min 

Administer

1500 IU if IBW < 60kg and 2000 IU if IBW ≥ 60kg. Not recommended if HIT is present. Re-dose only once, then use Octaplasma if needed.

If

MA < 40 mm AND FF < 8 mm 

Administer
Platelets

1 adult dose, re-dose as needed

If

LY30 > 7.5% 

Administer
Aminocaproic Acid or Tranexamic acid 

Dose and re-dose according to what has been administered.

If

Hgb <80 g/L 

Administer
RBC

One unit at a time, followed by clinical reassessment

ALWAYS

Check and optimize

  1. 1

    Temperature >36 °C

  2. 2

    pH > 7.2

  3. 3

    iCa > 1.0 mmol/L

  4. 4

    Hgb > 75 g/L

If excessive bleeding persists despite normal TEG 5000, consider surgical re-exploration

Is transfusion complete and bleeding stabilized?

Neither available

Last updated: 16-JUL-2026
SOURCE
  • FARES-II, 2025
  • FIBRES, 2019
  • SCA, 2019
  • Octaplex PM, 2026
  • Fibryga PM, 2025
Fibryga and Octaplex are approved in Canada for this use

Thresholds when neither ROTEM nor TEG available

As directed by protocol

If

ACT > baseline

Administer
Protamine

10-50 mg prn   

If

Fibrinogen <1.5 g/L

Administer

4g, re-dose as needed

If

INR > 1.5

Administer

1500 IU if IBW < 60kg and 2000 IU if IBW ≥ 60kg. Not recommended if HIT is present. Re-dose only once, then use Octaplasma if needed.  

If

Platelet count < 50 x 10⁹/L - 100 x 10⁹/L

Administer
Platelets

1 adult dose, redose as needed   

If

Bleeding persists

Administer
Aminocaproic Acid or Tranexamic Acid 

Dose and re-dose according to what has been administered.

If

Hgb <80 g/L 

Administer
RBC

One unit at a time, followed by clinicial reassessment

ALWAYS

Check and optimize

  1. 1

    Temperature >36 °C

  2. 2

    pH > 7.2

  3. 3

    iCa > 1.0 mmol/L

  4. 4

    Hgb > 75 g/L

If excessive bleeding persists despite normal labs, consider surgical re-exploration

Is transfusion complete and bleeding stabilized?

Post-Partum

This is a scenario-based simulator. No patient information should be entered, and the tool does not record what you enter.

What is the situation?

Preparing for a bleed

Source
  • WHO-FIGO-ICM Consolidated Guidelines for PPH, 2025
  • Robinson et. al, 2022
  • Leduc et. al, 2009
Step 1

Readiness

  1. 1

    At admission: perform high-risk assessment.

  2. 2

    If high-risk: send group & screen; calculate MABL (maximum allowable blood loss).

  3. 3

    At birth: give a uterotonic immediately - carbetocin preferred over oxytocin.

  4. 4

    Room/team readiness: hemorrhage cart/tray; MHP activation criteria; team role assignment; IV access; POC/VET testing availability; blood-bank notification; uterotonic + fibrinogen concentrate availability; temperature & calcium.

As directed by protocol

Next

Source
  • WHO-FIGO-ICM Consolidated Guidelines for PPH, 2025
  • Robinson et. al, 2022
Step 2

Diagnose

  1. 1

    Trigger: ≥300 mL blood loss AND ≥1 abnormal hemodynamic sign; OR ≥500 mL blood loss.

    Send group & screen (if not already done)

  2. 2

    Recommend: send fibrinogen test & VET (viscoelastic testing).

NOTEAs directed by protocol

Which track would you like to simulate?

In practice: both tracks run at the same time. Control (OB / surgeon) works source control while Replenish (anesthetist) works hemostatic resuscitation. Escalation occurs at any point if hemodynamically unstable and no source control

Track A - Control (source control, led by the OB / surgeon)

source
  • WHO, 2023
  • E-MOTIVE trial, 2023
  • WOMAN trial, 2017
  • Robinson et. al, 2022
  • Royal College of Obstetricians and Gynaecologists, 2017
Control

Managing an active bleed

  1. 1

    eMOTIVE bundle

    • Uterine massage
    • Oxytocic drugs
    • Administer tranexamic acid (TXA) 1 g IV — early, first-line
    • Second IV access (IV fluids)
  2. 2

    If bleeding continues: 2nd/ 3rd line uterotonic

    • Misoprostol
    • Ergometrine
    • Carboprost
  3. 3

    If bleeding continues: minimally invasive

    • Intra-uterine tamponade
    • Compression sutures (B-Lynch)
  4. 4

    If bleeding continues: advanced options

    • Uterine / internal iliac artery ligation
    • Embolization (if available)
  5. 5

    Hysterectomy

    • Consider sooner if the patient is hemodynamically unstable, OR ≥4 units RBC given with no source control.
NOTEAs directed by protocol

Escalation rule

Escalate at any point if hemodynamically unstable and no source control.

If

Shock Index 1.0–1.4

Then
Begin uncrossmatched blood, consider MHP

If

Shock Index > 1.4

Then
Activate MHP immediately

Click here to visit MHP simulator

Next

Post-bleed management

Repeat core labs once (CBC / PT / APTT / INR / Fibrinogen) and/or VET as clinically indicated.
Transfuse RBC one unit at a time with reassessment, guided by Hb target and volume status (target Hb 70–90 g/L).

Acknowledgements

Adapted from references listed above, with clinical oversight by Dr. Ron George

Track B - Replenish (hemostatic resuscitation, led by the anesthetist)

Source
  • Robinson et. al, 2022
  • Schroll et. al, 2018
  • ORBCoN MHP Tooklit
Replenish

Managing an active bleed

  1. 1

    Optimize patient

    • Administer calcium: ionized Ca²⁺ > 1.1 mmol/L; uncorrected (non-ionized) Ca > 2.14 mmol/L.
    • Maintain temperature > 36 °C.
    • Maintain pH > 7.2.
  2. 2

    Crystalloids

    • Goal = euvolemia. Replace QBL 1:1 with crystalloid until MABL reached, if hemodynamically stable.
    • Volume not to exceed 4 L (except low-resource setting, to preserve organs).
  3. 3

    Blood

    • Goal = euvolemia. Target Hb 70–90 g/L. Use uncrossmatched if crossmatched not available.
    • If shock index 1.0–1.4: begin uncrossmatched, consider MHP
    • If shock index > 1.4: activate MHP immediately.
  4. 4

    Coagulation management

    • Based on available point-of-care testing

What point-of-care testing is available?

ROTEM (FIBTEM / EXTEM)

Replenish fibrinogen

Does the uncontrolled severe bleeding arise in the course of a surgical intervention (e.g. caesarean section, intra-operative)?

Yes

Source
  • Robinson et. al, 2022
  • Mallaiah et. al, 2015
  • Fibryga PM, 2025
Fibryga is approved in Canada for this use

Transfusion thresholds

Obstetric fibrinogen target: > 2 g/L

If

FIBTEM A5 8-12 mm

Then

If

FIBTEM A5 5-8 mm

Then

If

FIBTEM A5 <5 mm

Then

Next

Source
  • Robinson et. al, 2022

Replenish plasma

Transfusion thresholds

If

EXTEM CT ≤ 75 s or normal PT/APTT

Themn
no Octaplasma required

If

EXTEM CT > 75 s or abnormal PT/APTT

Themn

or ≤50 kg = 3U; > 50 kg = 4U

Replenish platelets

Transfusion thresholds

If

If platelet count < 50 x 10⁹/L or an impending drop < 50 x 10⁹/L

Then
Administer platelets

1 adult dose

What is the situation?

Hemodynamic instability

After replenishment

If

Hemodynamic instability

Then
Activate MHP

Click here to visit MHP simulator

No

Source
  • Robinson et. al, 2022
  • Mallaiah et. al, 2015
No FC is approved in Canada for this indication; use is guideline-supported

Transfusion thresholds

Obstetric fibrinogen target: > 2 g/L

If

FIBTEM A5 8-12 mm

Then
4g FC

If

FIBTEM A5 5-8 mm

Then
6g FC

If

FIBTEM A5 <5 mm

Then
8g FC

TEG / Quantra (CFF-MA)

Replenish fibrinogen

Does the uncontrolled severe bleeding arise in the course of a surgical intervention (e.g. caesarean section, intra-operative)?

Yes

Source
  • Robinson et. al, 2022
  • Mallaiah et. al, 2015
  • Fibryga PM, 2025
Fibryga is approved in Canada for this use

Transfusion thresholds

Obstetric fibrinogen target: > 2 g/L

If

CFF-MA 14–19 mm

Then

If

CFF-MA 7–14 mm

Then

If

CFF-MA < 7 mm

Then

Next

Source
  • Belin et. al, 2025
  • Robinson et. al, 2022
  • Sarani et. al, 2025

Replenish plasma

Transfusion thresholds

If

QUANTRA CT < 127 s or TEG: CK-R < 10 min

Then
no Octaplasma required

If

QUANTRA CT > 127 s or TEG: CK-R >10 min

Then

or ≤50 kg = 3U; > 50 kg = 4U

Replenish platelets

Transfusion thresholds

If

If platelet count < 50 x 10⁹/L or an impending drop < 50 x 10⁹/L

Then
Administer platelets

1 adult dose

What is the situation?

No

Source
  • Robinson et. al, 2022
  • Mallaiah et. al, 2015
No FC is approved in Canada for this indication; use is guideline-supported

Transfusion thresholds

Obstetric fibrinogen target: > 2 g/L

If

CFF-MA 14–19 mm

Then
4g FC

If

CFF-MA 7–14 mm

Then
6g FC

If

CFF-MA < 7 mm

Then
8g FC

Neither available

Replenish fibrinogen

Does the uncontrolled severe bleeding arise in the course of a surgical intervention (e.g. caesarean section, intra-operative)?

Yes

Source
  • Robinson et. al, 2026
  • Fibryga PM, 2025
Fibryga is approved in Canada for this use

Transfusion thresholds

Obstetric fibrinogen target: > 2 g/L

If

Fibrinogen level < 2 g/L

Then

If

Fibrinogen level < 1.5 g/L

Then

If

Fibrinogen level < 1 g/L

Then

Next

Source
  • Robinson et. al, 2022

Replenish plasma

Transfusion thresholds

If

If INR < 1.8

Then
no Octaplasma required

If

If INR ≥ 1.8

Then

or ≤50 kg = 3U; > 50 kg = 4U

Replenish platelets

Transfusion thresholds

If

If platelet count < 50 x 10⁹/L or an impending drop < 50 x 10⁹/L

Then
Administer platelets

1 adult dose

What is the situation?

No

Source
  • Robinson et. al, 2026
No FC is approved in Canada for this indication; use is guideline-supported

Transfusion thresholds

Obstetric fibrinogen target: > 2 g/L

If

Fibrinogen level < 2 g/L

Then
4g FC

If

Fibrinogen level < 1.5 g/L

Then
6g FC

If

Fibrinogen level < 1 g/L

Then
8g FC

Select a scenario: Which bleeding situation is being managed?

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For HCP only. Content does not constitute medical advice and is not a substitute for clinical judgment. T&C apply