Massive Haemorrhage Tutorial Flashcards
Describe how we can define massive haemorrhage by volume and rate of blood loss
One blood volume in 24 hours
50% blood volume in 3 hours
Blood loss of 150ml/minutes
Obstetrics:
- Minor 500-1000ml
- Major >1000ml
How can we define massive haemorrhage by clinical situation?
Bleeding which leads to a HR of >110 bpm and/or SBP less than 90mmHg
Bleeding which has already prompted use of emergency O Rh(D) negative red cells
How do we manage massive haemorrhage?
Blood component support
Stop the bleeding
What is a massive haemorrhage protocol?
- Facilitates prompt transfusion of appropriate blood and blood components and streamlines communication between bloodbank and clinical area
- Allows a standardised approach to the initial management of massive haemorrhage
- Activation allows emergency issue of blood components for bleeding patients without the authorisation of a haematologist
What are some things you must do in massive haemorrhage?
Must perform all usual safety checks before transfusion
Must complete all usual documentation
Must consider thromboprophylaxis once bleeding controlled
Fresh frozen plasma does what?
Replace coagulation factors and help maintain coagulation close to normal
What ratio of RBC to FFP do we do in first instance of massive haemorrhage?
2RBC: 1FFP
What RBC to FFP ratio do we do in trauma?
1:1
A 25 year old woman delivered her first baby 30 minutes ago via normal vaginal delivery. The midwife in Labour Ward calls you to see her because she looks pale and her blood pressure has dropped to 80/60mm/Hg. There is evidence of large volume vaginal blood loss.
* What is your initial approach to management?
ABCDE
Activate massive haemorrhage protocol + ask for senior help
Gain large bore IV access
Send emergency blood samples including crossmatch sample if required
Start fluid resus
Move patient to high dependency area for ongoing management
Start transfusion of blood components when they arrive
- You have activated the major haemorrhage policy and the patient has been transfused 2 units of red cells and 2 units of FFP. How will you monitor response to this initial treatment?
Monitor BP and pulse every 15 minutes
Blood tests- FBC and coagulation screen every 30-60 minutes until bleeding controlled
- What specific interventions might you consider to help control post partum haemorrhage? Are there any abnormalities of coagulation that you should pay particular attention to?
Tranexamic acid
Consider use of cryoprecipitate early (if fibrinogen <2g/L)
Obstetric
- Pharmacological: oxytocin, ergometrine
- Mechanical: uterine massage, empty bladder with catheter
- Surgical: uterine balloon tamponade, haemostatic suturing, artery ligation, interventional radiology to embolise, hysterectomy
Thromboprophylaxis once bleeding controlled
Scenario 2- Traumatic haemorrhage
A 30 year old man has been involved in a road traffic collision where his motor bike was struck by a lorry. He has been transfused 2 units of red cells pre-hospital by the trauma team. On arrival at the ED, he is shocked with BP 90/60, HR 120. There is extensive bruising over his abdomen and he complains of pelvic pain.
* What is your initial approach to management?
ABCDE
Activate massive haemorrhage protocol and call for senior help
Gain large bore IV access
Send emergency blood samples including crossmatch sample if required
Start fluid resus
Start transfusion of blood components when they arrive
- What specific interventions might you consider to investigate and treat major haemorrhage in the context of trauma?
Tranexamic acid given within 3 hours of injury
Imaging to assess internal injuries
Splinting of possible pelvic fracture
Surgical / radiological intervention to stop internal bleeding
Importance of thromboprophylaxis once bleeding controlled
Scenario 3- Variceal haemorrhage
A 64 year old woman with a history of alcohol related liver disease has been admitted to the Acute Medical Unit with confusion. You are called to see her due to profuse and ongoing haematemesis. His blood pressure is 100/60, HR 130.
* What is your initial approach to management?
ABCDE
Activate massive haemorrhage protocol and call for senior help
Gain large bore IV access
Send emergency blood samples + crossmatch sample if required
Start fluid resus
Move patient to high dependency area for ongoing management
Start transfusion of blood components when they arrive
Scenario 3- Variceal haemorrhage
A 64 year old woman with a history of alcohol related liver disease has been admitted to the Acute Medical Unit with confusion. You are called to see her due to profuse and ongoing haematemesis. His blood pressure is 100/60, HR 130.
What specific interventions might you consider to investigate and treat major haemorrhage in this context?
Pharmacological - terlipressin, vitamin K, antibiotics
Blood component - patient may have pre-existing coagulopathy and may require FFP / cryo to correct this
Endoscopic - banding of varicose / sclerotherapy
Sengstaken-blakemore tube
TIPPS