Acute haemorrhage

Question 1

Why might young patients not be tachycardic despite a significant bleed?

Answer 1

Preserved vascular tone meaning they compensate for the bleed for longer by maintaing CO with vasoconstriction

Question 2

Signs of abdominal bleeding on inspection?

Answer 2

Cullen’s/ Turner’s sign

Question 3

What causes Cullen’s sign?

Answer 3

Cullen’s is hamorrhagic discolouration around to umbillicus due to intraperitoneal bleeding

• Acute pancreatitis
• Rupture ectopic pregnancy
• Blunt force trauma to abdomen
• Ovarian cyst haemorrhage
• Ischaemic + gangrenous bowel
• Ruptured aorta

Question 4

What causes Turner’s sign?

Answer 4

Turner’s is bruising of the flank due to retroperitoneal haemorrhage

• Severe necrotising pancreatitis
• Ruptured AAA
• Ruptured ectopic
• Ruptured spleen

Question 5

What could promote bleeding?

Answer 5

Anticoagulants

High BP

Liver failure

Question 6

American college of surgeons acute haemorrhage classification

Answer 6

Stage 1: <750mL

Stage 2: 750-1500mL

Stage 3: 1500-2000mL

Stage 4: >2000mL

Question 7

What is major haemorrhage?

Answer 7

50% blood loss within 3hrs or at a rate >150mL/ min - think equals ~2.5L in a 70kg male

Question 8

What can make bleeding worse?

Answer 8

HAC​

1. Hypothermia
2. Acidosis
3. Coagulopathy

Known as the lethal triad

Question 9

Haemostatic resuscitation following major haemorrhage

Answer 9

Used red cell concentrates

Avoid using crystalloid because it dilutes clotting factors and can make bleeding worse

Question 10

What is permissive hypotension?

Answer 10

Following major haemorrhage aim for a systolic BP of 80-90

This prevents high pressures breaking down clots

Fentanyl used to lower BP: symaptholysis and analgesia

Question 11

Managing the haemorrhaging patient

Answer 11

Oxygen: they have a low Hb so the Hb they do have needs to be saturated with oxygen to prevent hypoperfusion

Establish IV access: 2 wide bore cannulas

Bloods: FBC (Hb and platelets), renal profile, U&E (hypocalcaemia can worsen bleeds), liver profile, clotting profile, group and save

CT angio: where are they bleeding from

Warmed IV fluid/ blood products to prevent hypothermia (part of the lethal triad)

Question 12

How to control a bleed

Answer 12

• Direct pressure e.g. splints/ pelvic binders
• Red cell concentrate
• TXA: some trials show it is of benefit, others don’t
• Permissive hypotension: aim for a MAP of 65 (sBP+dBP+dBP/3)

*If MAP >65 consider using fentanyl to lower it

• Correct clotting deficits

Question 13

What does a star sign in CT angiography indicate?

Answer 13

Subarachnoid haemorrhage

Question 14

What is cryoprecipitate?

Answer 14

Contaings fibrinogen, vWF, factor VIII, factor XIII

Given to patients with fibrinogen deficiency and those with haemophilia A (factor VIII deficiency)

Question 15

What is given to patients with major haemorrhage on warfarin?

Answer 15

Prothrombin complex concentrate

Replaces vitamin K dependent factors 2, 7, 9 and 10 - always give with vitamin K

Question 16

What is given to patients with vWF deficiency?

Answer 16

vWF promotes platelet aggregation and adhesion

If deficient, in cases of haemorrhage patients are given desmpressing or vWF concentrate

Question 17

Patient is thrombocytopenic (<30x10*9) - what do we do?

Answer 17

Give platelets…

Aim: 100x10*9

Question 18

Idaracizumab?

Answer 18

Used to reverse dabigatran

Monoclonal antibody that binds to dabigatran and its metabolites and reverses its effects

Question 19

1 unit of packed red cells will increase the Hb by how much?

Answer 19

10g/L (1g/dL)

Question 20

Target Hb following blood transfusion

Answer 20

After giving packed red cells aim for:

- 70-90g/L (7-9g/dL) Hb

- 80-100g/L (8-10g/dL) Hb in those with acute coronary syndrome

Question 21

Threshold value for giving packed red cells

Answer 21

70g/L Hb

Question 22

Target platelet count in major haemorrhage

Answer 22

100x10*9/ L

Question 23

What is the recommended dose of fresh frozen plasma?

Answer 23

12-15ml/kg - on average this is 4 units of FFP

This equates to 3-6 units of FFP depending on the patient’s weight

*Volume of FFP in a unit is variable - on average 275ml/ unit

Question 24

Clinical indications for fresh frozen plasma use

Answer 24

1. Major haemorrhhage: give ratio of FFP: packed red cells 1:1 or 1:2
2. PT/ INR >1.5 with bleeding: aim for PT and APTT ratio of <1.5
3. Liver disease
4. Thrombocytic thrombocytopenic purpura
5. Replacement of single clotting factor

Question 25

When would we give cryoprecipitate?

Answer 25

In major haemorrhage if fibrinogen is \<1.5g/L

Question 26

Avoiding the lethal triad in major haemorrhage

Answer 26

**Hypothermia:** - Remove wet clothing, ensure ambient temperature appropriate, continually monitor temp (rectal probe), use warming blankets, tranfuse warmed blood products **Acidosis:** - Inadequate tissue perfusion = lactic acidosis which can impair clotting - Restore tissue perfusion ASAP with blood products (not crystalloids as these dilute existing blood) - Maximise oxygenation and minimise hypoventilation to avoid respiratory acidosis **Coagulopathy:** - Avoid large volumes of crystalloid or unbalanced blood products because these can cause dilutional coagulopathy - Liaise with haematology from beginning - Manage major haemorrhage patient as though they are coagulopathic

Question 27

What is the ideal ratio of blood products in major haemorrhage?

Answer 27

2:1:1 Packed RBCs: FFP: platelets \*This does vary depending on trust\*

Question 28

Which electrolyte derrangement is associated with increased bleeding risk?

Answer 28

Hypocalcaemia

Question 29

What is upper GI bleeding?

Answer 29

Bleeding from the GI tract above the ligament of Treitz

Question 30

How might a GI bleed be recognised?

Answer 30

70% have melaena 50% have haematemesis PAtients with hx of liver disease, recent profuse vomiting (Mallory Weiss), peptic ulcer disease, alcohol use, NSAIDs \*Important to do a PR early as melaena may be present\*

Question 31

What scoring systems can be used to identify high risk upper GI bleeds?

Answer 31

**Glasgow-Blatchford - pre endoscopy** - To identify those who can be discharged and those who will need intervention - Score of 0: consider discharge with outpatient endoscopy **Rockall - post endoscopy** - To identify patients at risk of adverse outcome following acute upper GI bleeding - Score \<3 = good prognosis - Score \>8 = high risk of mortality

Question 32

Investigations for upper GI bleed

Answer 32

VBG: Hb level U&E: urea raised as blood digested in stomach FBC Coagulation screen LFTs Cross match

Question 33

Management of upper GI bleeds

Answer 33

**1st: Use Glasgow-Blatchford score to assess risk** Offer blood transfusion if Hb \<8g/dL **a) Non-variceal bleed** - PPI: reduces bleeding by increasing pH of gastric environment =which promotes clot stability - Urgent endoscopy: use adrenaline + clips/ thermal coagulation/ firbin or thrombin **b) Variceal bleed** - Terlipressin: causes arterial constriction - Band ligation \*If endoscopy treatment fails to control the bleeding, consider TIPS procedure\*

Question 34

What should be given to every patient in A&E with suspected variceal haemorrhage?

Answer 34

Terlipressin + broad spectrum antibiotics

Question 35

Gold standard for diagnosing and treating upper GI haemorrhage?

Answer 35

Endoscopy - controls bleeding in 90% patients with bleeding peptic ulcers

Question 36

What is used to control upper GI bleeding if medical therapy not working and endoscopy not immediately available?

Answer 36

Balloon tamponade - the idea is to buy time until endoscopy available

Question 37

What is transfusion associated circulatory overload?

Answer 37

Transfusion reaction that can occur due to rapid transfusion of a large volume of blood Causes hypervolaemia Can worsen oedema, cause tachycardia, increase BP, worsen pulmonary oedema Management: stop transufsion, oxygen, diuretics \*Important to consider giving blood based on body weight and consider giving prophylactic diuretic\*

Question 38

Which MAB can reverse dabigatran?

Answer 38

Idarucizumab

Question 39

Patient is on warfarin and is haemorrhaging - what do we do?

Answer 39

Stop warfarin, give phytomenadione (vitamin K1) and prothrombin complex \>\> If prothrombin complex not available, five FFP - not as effective but better than nothing \<\<