Massive Haemorrhage

Question 1

What is a massive haemorrhage

Answer 1

Bleeding patient
- with signs of shock,
- which has prompted use of emergency O Rh(D) neg RBCs
- with a HR>110 &/ systolic bp <90mmHg

Question 2

Massive haemorrhage protocol example

Answer 2

• Send urgent blood samples
  (FBC, coagulation screen, fibrinogen, cross match, U&Es, Ca)
• Notify blood bank who will send
  (4 units RBCs, 4 units FFP, 1 unit platelets)

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• ABCDE approach
• Large bore IV access
• IV fluids
• Call for help
• transfuse RBCs/ FFP/ platelets

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• Repeat blood samples
• If ongoing bleeding:
  
  • RBC:FFP transfusion @ 2:1 ratio or 1:1 if in trauma
  • Cryoprecipitate if fibrinogen <1gL (or <2g/L if obstetric)

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• Maintain bloods at:
  
  • Hb > 80g/L
  • APTT and PT ratio <1.50
  • Fibrinogen >1.50g/L (or >2g/L if obstetric)

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• Consider thromboprophylaxis once bleeding is controlled

Question 3

Massive haemorrhage management involves blood component support (supportive) & bleeding stop (definitive). What is the uses of the different blood components?

Answer 3

• RBCs - maintain oxygenation, replace RBCs & Hb
• FFP - replace coagulation factors
• Platelets - replace platelets
• Cryoprecipitate - replace fibrinogen

Question 4

How would you monitor a patients response to massive haemorrhage treatment

Answer 4

Repeat ABCDE every ~15mins
BP & HR (observations) monitoring
Repeat bloods

Question 5

Postpartum haemorrhage definitive control

Answer 5

1) Uterine massage & tranezamic acid
2) (if massage doesn’t work) e.g. Balloon tamponade OR uterine artery balloon occlusion
3) Hysterectomy (last resort)

Question 6

Traumatic haemorrhage definitive control

Answer 6

1) Tranezamic acid & imaging (bleeding control)
2) Consider where the patient needs to go e.g. ICU or theatre
- will often do life saving treatment then ICU
- & then have surgery the next day

Question 7

Variceal haemorrhage definitive control

Answer 7

1) Variceal banding & ligation
2) Endoscopy
3) If banding fails - TIPS procedure (last resort)

NOTE: consider if patient has coagulopathy (associated with liver disease)

Question 8

Ruptured AAA definitive control

Answer 8

1) US or CT
2) Emergency surgery

NOTE: may or may not prescribe tranezamic acid (may increase risk of clot where stent is placed)

Question 9

In what type of bleeding in tranezamic acid not recommended

Answer 9

GI bleeding

Question 10

How does tranezamic acid work?

Answer 10

Inhibits activation of plasminogen to plasmin
This prevents the degradation of fibrin