Management of Major Haemorrhage

(See site specific information below)

Introduction

The therapeutic goal in the management of massive haemorrhage is maintenance of tissue perfusion and oxygenation by restoration of blood volume and haemoglobin (see site specific information below)

Definition of major haemorrhage

Definition of acute massive haemorrhage varies. It can be defined as a 50% blood loss within 3 hours or a rate >150ml/minute.

The normal human blood volume in an adult is 65-70ml/kg; therefore a 70kg male has a blood volume of approximately 5000ml - a 50% loss is approximately 2500ml.

1. Assess: Is this major haemorrhage? (See definition above)

2. Restore circulating volume

• Wide bore peripheral cannulae
• Controlled hypotension may be tolerated while awaiting the arrival of CRC for administration. However, where necessary, adequate volumes of crystalloid or colloid, warmed if possible should be given.
• Give oxygen and start monitoring
• Aim for BP at appropriate level

3. Summon Help (see site specific information below). Seek senior staff assistance:

• Surgical?
• Anaesthetics?
• ITU?
• Obstetric?
• Emergency medicine?

4. Stop bleeding

Consider early surgical, obstetric or interventional radiology involvement.

5. Send blood samples

• Emergency crossmatch: 6 units of red cells (RBC) will be made available – request as appropriate 
• FBC and clotting screen including fibrinogen. If ROTEM (rotational thromboelastometry) or TEG (thromboelastography) available, these may also be performed to guide therapy.
• Biochemistry including calcium
• Ensure correct labelling of samples
• NHSGGC operates a second confirmatory sample policy before group-specific or cross-matched blood will be issued; consideration should be given to obtaining a second sample. Group O blood will be issued unless there is a second sample available to confirm blood group. Group O negative will always be issued for females <50 years. O negative or O positive may be issued for male patients and females over the age of 50 years.
• Consider requirement for ABGs

6. Give blood products as appropriate (see below)

Blood products

• 6 units of RBC will be made available. Request as appropriate. The decision to use O negative, group specific or fully cross-matched blood is a clinical one. Delays in transfusion must be avoided. Please note: Blood bank may issue O positive blood for male patients and females over the age of 50 years in an emergency. 
• Where the patient being transfused has special requirements, it may be necessary to discuss with the Blood Transfusion lab +/- a Haematologist if there are problems fulfilling these requirements in order for the best available blood to be issued. There should be no delay in transfusion while waiting for appropriate blood.
• If the major haemorrhage is associated with trauma or is obstetric in nature with an early risk of Disseminated Intravascular Coagulation (DIC), 4 units of fresh frozen plasma (FFP) will be thawed for use on request. 
• If platelets are specifically required, it is necessary to request them. The 6 units of RBC, 4 units of FFP +/- platelets constitute Trauma Pack A.
• If bleeding is ongoing after administration of Pack A, Trauma Pack B should be requested (4 units of RBC, 4 units of FFP, 1 unit of platelets and 2 pools of cryoprecipitate).
• The laboratory staff will contact the duty Haematologist if Pack B is requested, to help guide therapy.
• Once the results become available these should be used the guide therapy.

Patients on anti-thrombotic therapy

• For patients on warfarin, prothrombin complex concentrate should be administered. Discussion may need to take place between clinicians and haematologists to discuss the risks and benefits of reversal for the patient.
• For patients on direct oral anticoagulants (DOACS - apixaban, dabigatran, edoxaban, or rivaroxaban) discuss with a Haematologist regarding specific reversal agents available.

In Massive Transfusion remember:

Allow at least:

• 20 minutes for thawing of plasma products
• 25 minutes for group specific red cells
• Up to 60 minutes for full crossmatch unless antibodies are present in which case least incompatible will be issued 
• Transport time

Other Information

• If emergency O negative used please inform Haematology / Blood Transfusion lab as soon as possible to ensure replacement of units.
• Avoid wastage of blood products - return blood immediately to the Blood Transfusion lab or satellite fridge if not being used.
• Packed red cells should not be lying out of fridge for more than 30 minutes. If a unit of blood will not be used in that time, it should be returned to the blood fridge, if however this has not occurred the unit can be transfused up to 4 hours from removal from fridge to minimise wastage.   
• Once situation resolved, inform lab staff and porters to allow them to stand down.
• Once cycle completed review clinical situation.
• Tranexamic acid - This has been shown to safely reduce the risk of death in bleeding trauma patients (CRASH 2 Trial). Dose is tranexamic acid IV 1g over 10 minutes, then infusion of 1g over 8 hours. The recent HALT-IT study has shown that there is no benefit in the use of tranexamic acid in gastric bleeds. Check local protocols but its use outside of clinical trials in this group is not currently recommended.

Hospital Specific Information on Massive Haemorrhage Management

Guideline reviewed: April 2024

Page last updated: July 2024