Major Haemorrhage

Definitions

There is no universal definition but the following would usually fall within the category:

1. Loss of >50% blood volume in <4hrs (2.5l for 70kg adult)
2. Loss of >150ml/min for an adult
3. Need for O negative blood
4. Need for 4 units blood stat
5. Ongoing haemodynamic instability due to ongoing blood loss despite resuscitation

How to Activate a Major Haemorrhage Response

1. Call for help
2. Nominate a coordinator
3. Coordinator calls switchboard on 2222 stating major haemorrhage and giving patient ID (Name and CHI Number), location, specialties required and coordinator contact number
4. Switchboard will call blood bank, capacity manager and relevant specialties
5. Blood bank will call coordinator for clinical condition, requirements and timescale

Fluid Resuscitation & Temperature Conservation

1. Avoiding hypothermia is essential, cold patients bleed more, consume more oxygen and become acidotic
2. Warm IV fluids via IV warmer or ‘Level 1’ infuser and use Bair Hugger where possible
3. Crystalloid or colloid may be used but as crystalloid can be pre-warmed and is widely available it is a rational first choice.
4. The crystalloid of first choice is Hartmann’s as unlike saline it does not cause a metabolic acidosis when used at large volume. 5mmol/l of potassium in Hartmann’s is rarely clinically relevant.
5. The colloid of first choice is Gelaspan as it causes less effect on coagulation than other widely available colloids
6. Avoid large volume crystalloid/colloid resuscitation – use blood products as soon as available

Red Blood Cells

1. The URGENCY to transfuse red blood cells is a CLINICAL one that needs to be defined BEFORE blood is requested from the blood bank.
2. The standard initial order in major haemorrhage is Massive haemorrhage 1 request which contains 4 units packed cells and 4 units FFP

Specific Scenarios (click link to Guideline)

1. Trauma incl when to give tranexamic acid
2. Reversal of warfarin
3. Reversal of antiplatelet therapy
4. Major haemorrhage post thrombolysis
5. Reversal of LMWH
6. Reversal of unfractionated heparin
7. Reversal of newer anticoagulant agents
   

   Red Cell Product	Lab Preparation Time	Tyopical Clinical Indication
   Group O	None	Hypovolaemia with poor haemodynamic response to first fluid bolus. Severe uncontrolled haemorrhage.
   Type Specific	25 minutes	Hypovolaemia with good initial response to first fluid bolus but uncontrolled moderate bleeding
   Fully cross matched	30 minutes (assuming no irregular antibodies)	Controlled haemorrhage and hypovolaemia but likely anaemia or further bleeding anticipated

Resuscitation End Points

1. If haemorrhage is controlled resuscitation aims to normalise parameters of circulation and parameters of organ perfusion (skin, urinary output etc). This may require specialist monitoring techniques – Anaesthetist will advise.
2. If haemorrhage is ongoing resuscitation aims to sustain life and avoid overtransfusion, targeting low-normal blood pressure until haemorrhage is controlled.

Treatment Targets (click link to Guideline)

1. Hb 80-100g/l
2. Platelets >75,000
3. INR <1.5
4. APTTR <1.5
5. Fibrinogen >1.5g/l
6. Ionised calcium >1mmol/l
7. Corrected calcium >2.12mmol/l

Complications of Rapid Transfusion (click link to Guideline)

1. Hypothermia
2. Hyperkalaemia
3. Acidosis
4. Hypocalcaemia
5. Coagulopathy

Links

• Major Haemorrhage Guideline
• DGRI Major Haemorrhage Protocol
• GCH Major Haemorrhage Protocol
• Blood Transfusion
• Management of Transfusion Reactions

Content by Dr James Neil