GGC Medicines


Adult Therapeutics Handbook

Management of Major Haemorrhage

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. Please note: Blood bank may issue O positive blood for male patients and females over the age of 50 years in an emergency. 
  • 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.
Blood product Important Information
Red cells
  • Aim Hb >80g/L (8g/dL)
  • O negative from Blood Bank or satellite fridges (see below for details)
  • Group specific 25 minutes
  • Full crossmatch 60 minutes
Clotting factors
  • FFP: aim for PT and APTT <1.5x control (PT <18 seconds and APTT <45 seconds)

    and/or

  • Cryoprecipitate: aim fibrinogen >1.5g/L
Platelets
  • Aim >80x109/L, >100x109/L if multiple or CNS trauma
  • Stocks held at Gartnavel so may take >1 hour to arrive

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

Royal Alexandra Hospital (RAH)
Phone numbers Blood storage (O negative blood) Key personnel Coagulation factors
Call switchboard 2222 and state "Major Haemorrhage", name of hospital and location Theatre Fridge, Maternity Fridge (4 units) On-call Haematology BMS. Porter via 2222 call. Issued after discussion with on-call Haematology BMS or Haematology medical staff.
Inverclyde Royal Hospital (IRH)
Phone numbers Blood storage (O negative blood) Key personnel Coagulation factors
Call switchboard 2222 and state "Major Haemorrhage", name of hospital and location Transfusion Laboratory, Haematology Department, Level C. Out-of-hours satellite fridge opposite Transfusion Office level C (4 units), Theatre level M fridge (2 units). On-call Haematology BMS via switchboard Issued after discussion with on-call Haematology BMS or Haematology medical staff.
Vale of Leven (VOL)
Phone numbers Blood storage (O negative blood) Key personnel Coagulation factors
Call Blood Transfusion Laboratory extension 27502. Out of hours, call person in charge (Hospital at Night) and state "Major Haemorrhage", name of hospital and location. On-call Haematology BMS via switchboard, Transfusion Laboratory. Out-of-hours satellite fridge in theatre corridor (2 units). Porters will bring if asked. On-call Haematology BMS via switchboard and Hospital at Night team. Please note if a major haemorrhage occurs out of hours, immediate plans should be made to transfer the patient to the RAH whilst resuscitation continues. Issued after discussion with on-call Haematology BMS via switchboard or Haematology medical staff. Please be aware that the patient should be transferred to the RAH at the earliest opportunity as their clinical condition allows.
Stobhill ACH
Phone numbers Blood storage (O negative blood) Key personnel Coagulation factors
No Blood Bank on site. Call switchboard 2222 and state "Major Haemorrhage Stobhill ACH" and location, including local extension number. Call Blood Bank 24666 / 25047 ACH Laboratory satellite fridge (6 units) On-call Haematology BMS via switchboard. Call switchboard and request an emergency taxi to take any samples to GRI Blood Bank. Issued after discussion with Haematology medical staff, guided by clotting results.
Queen Elizabeth University Hospital (QEUH)
Phone numbers Blood storage (O negative blood) Key personnel Coagulation factors
Call 2222 and state "Major Haemorrhage", name of hospital and location of patient

A&E (6 units) - located in the Immediate Assessment Unit (IAU)

Critical care (2 units) - located outside medical High Dependency Unit (HDU5)

Theatre (Haemobank) (6 units)

Labour suite (3 units)

INS, ward 60 (2 units)

On-call Haematology BMS page 7602.

MLA page 7262

Blood Bank will automatically thaw 4 units of FFP. Further units issued once clotting screen received in lab and discussion with medical staff.
Victoria ACH
Phone numbers Blood storage (O negative blood) Key personnel Coagulation factors
Call switchboard 2222 and state "Major Haemorrhage", name of hospital and location. Also call 5555 for Porter.

ACH fridge (6 units)

BMS page 6645. Blood bank at the QEUH extension 89104. If major haemorrhage out of hours, aim to transfer patient to QEUH - call 999 and transfer patient to A&E (QEUH A&E extension 82828) Blood Bank will automatically thaw 4 units of FFP. Further units issued once clotting screen received in lab and discussion with medical staff.
Gartnavel General Hospital (GGH)
Phone numbers Blood storage (O negative blood) Key personnel Coagulation factors

Call switchboard - 2222 and state "Major Haemorrhage", name of hospital and location. 

If the patient is in the Beatson, an arrest call should be activated in addition to the Major Haemorrhage alert to ensure the presence of an anaesthetist and the high acuity team if appropriate.

GGH Theatre (4 units), GGH Blood Bank

 Haemobank B7 (4 units)

Porters Office (2 units )

Blood Bank, Porters informed by switchboard

GGH Blood bank is only open 9am – 8pm Monday to Friday. Outwith these times it is covered by GRI blood bank who will contact you when the 2222 call is initiated

Blood Bank will automatically thaw 4 units of FFP
Glasgow Royal Infirmary (GRI)
Phone numbers Blood storage (O negative blood) Key personnel Coagulation factors

Call Switchboard 2222 and state "Major Haemorrhage", name of hospital and location.

Call Blood Bank 24666 / 25047.

Blood Bank - MacEwen Building.

A&E Fridge - Jubilee Building (4 units)

Satellite theatre fridge - Queen Elizabeth Building (2 units)

Labour ward fridge - Princess Royal Maternity (4 units)

Blood Bank, Porters, Anaesthetist informed by switchboard The first issue of FFP and platelets can be made without haematologist involvement. Subsequent requests must be authorised by the duty haematologist.

Guideline last reviewed and content updated March 2021