MAJOR HAEMORRHAGE

Question 1

Define major haemorrhage

Answer 1

Loss of more than one blood volume within 24 hours
50% of total blood volume lost in less than 3 hours
Bleeding in excess of 150 mL/minute

However, in an acute scenario, you are unlikely to be able to calculate blood loss as above. Therefore, a major haemorrhage can be considered as bleeding (visible or presumed) which results in:
A blood pressure <90mmHg systolic
A heart rate >110bpm

Question 2

Approach to bleeding differentials in acute trauma

Answer 2

“Blood on the floor and four more”

• The chest - haemothorax, which in trauma is most likely caused by a rib fracture causing damage to the intercostal blood vessels.
• The abdomen. from injury to a solid organ, such as the spleen, or major blood vessel
• The pelvis. classically from a pelvic fracture
• In a limb from a broken bone. fractured long bones, such as the femur, can account for a significant volume of blood loss

On the floor – bleeding from a visible wound.

Question 3

What is becks triad

Answer 3

Cardiac tamponade

Jugular venous distension
Quiet heart sounds
Hypotension

Question 4

You’ve done ABCDE and suspect major haemorrhage, what do you do next?

Answer 4

Gain IV access
- Insert at least one wide-bore intravenous cannula (14G or 16G) and take blood tests as discussed below.

Investigate the bleeding
- Bloods (FBC, U&Es, LFTs, Coagulation screen, Group & save (+/- crossmatch), Toxicology screen (if you suspect drug overdose), Lactate (to assess for evidence of inadequate end-organ perfusion Levels > 4mmol/L are associated with increased mortality)
- ECG looking for any abnormal rhythms which may be contributing to poor perfusion.
- Scans
WBCT for suspected occult intra-abdominal bleeding. CT scanning: whole-body CT scan is the most accurate, but the patient must be stable enough to tolerate the scan
Ultrasound: FAST ultrasound scanning is a relatively quick bedside imaging technique which can be used when immediate conveyance to CT is not feasible. However, it cannot rule out intra- or retroperitoneal bleeding.

Stop the bleeding
- For external (“on the floor”) bleeds, direct pressure and dressings can be used. In limb injuries, if this fails, you could consider a tourniquet.
- Internal bleeding from pelvic fractures can be controlled with a pelvic binder.
- tranexamic acid, and reversal of anticoagulation, should also be considered at this point. Use intravenous tranexamic acid ASAP in patients with major trauma and active or suspected active bleeding. (but not >3hrs from incident unless signs of hyperfibrinolysis)

Replace lost volume
- Replace lost volume
target MAP of 65mmHg
- Follow major haemorrhage protocol eg 2:1:1 Packed Red Blood Cells: Fresh Frozen Plasma: Platelets has been suggested to improve survival

Avoid the lethal triad
- Keep patient as warm as possible- remove wet clothes, blanket, bear hugger.
- Maximise oxygenation and reduce any causes of hypoventilation
- Use a haemostatic resuscitation approach rather than traditional approach
- Manage the major haemorrhage patient as though they are already coagulopathic

Monitor the following every 30-60 minutes to guide your management:
- Temperature
- Acid base
- Ionised Calcium – on your ABG/VBG
- PT/APTT/Clauss Fibrinogen and platelets
- FBC

Question 5

Dose tranexamic acid in major haemrorhage

Answer 5

Tranexamic acid (1g bolus followed by 1g over 8 hours) in all cases

Question 6

why is ionised calcium important in major ahemorrhage? what can you do to correct it?

Answer 6

Hypocalcaemia can be caused by ahemorrhage, hypocalcaemia leads to coagulopathy

Calcium Chloride – 10mls 10% over 10 minutes if ionised Ca <1.1

Question 7

what is used in warfarinised patients in major ahemorrhage

Answer 7

prothrombin complex and
Vitamin K

Question 8

what is the lethal triad

Answer 8

Hypothermia, acidosis and coagulopathy

Question 9

why is hypothermia part of the lethal triad?

Answer 9

impairs platelet function and enzymatic function within the clotting cascade.

Question 10

why is acidosis part of the lethal triad?

Answer 10

inadequate tissue perfusion leads to lactic acidosis which can impair clotting

Question 11

why should you give lots of oxygen and minimise causes of hypoventilation in major haemorrhage

Answer 11

to avoid any additional respiratory acidosis.

Question 12

why is goal MAP 65 and not higher?

Answer 12

Permissive Hypotension – a compromise between ensuring adequate tissue perfusion whilst reducing the risk of dilutional coagulopathy and clot disruption. (Based on animal studies, evidence is limited and BP target will vary from patient to patient. LITFL summary suggests a target MAP of 65mmHg.)