MASSIVE HEMORRHAGE

Control bleeding in ED/ICU/OR/Interventional Suite.

  1. Assess SpO2 and ventilation with view to early intubation.

  2. Review clinical condition and consider activation of massive transfusion protocol (MTP). 

  3. Insert large caliber central venous catheter (CVC) or two wide bore peripheral IV lines. 

  4. Reverse any anticoagulation therapy. 

  5. Request blood chemistry, CBC, ABG, type and screen, and coagulation panel including TEG/TEM (if available). 

  6. Give antifibrinolytic agent if bleeding started < 3hr prior and there are no contraindications. 

  7. Monitor hemodynamics and aim for MAP ≥ 65 mmHg but if suspected traumatic brain injury increase MAP ≥ 80 mmHg. 

  8. Strictly limit use of all non-blood product fluids.

  9. Monitor progress with CBC, coagulation panel, fibrinogen, ABG and iCa.

  10. Actively warm patient, IV fluids and room. 10 Make early contact with surgical or medical proceduralists depending on the etiology and site of bleeding.



Massive hemorrhage = significant bleeding leading to death within minutes if there is
failure to gain definitive control.


Indications to initiate MTP:

  • Assessment of Blood Consumption (ABC) score of 3 or 4.

MASSIVE HEMORRHAGE

  • Critical Administration Threshold: Initiate MTP if giving 3rd unit of RBCs in the first hour.
  • Significant hemorrhage with either shock or abnormal coagulation as determined by a senior clinician.
Non-Trauma
  • Significant hemorrhage with either shock or abnormal coagulation as determined by a senior clinician.
Early endotracheal intubation and mechanical ventilation is strongly recommended. Use vitamin K, prothrombin complex or protamine if indicated to reverse any anticoagulation. 

The intra-osseous route is only suitable for initial resuscitation until large bore IV access is established.

Blood chemistry should include SMA-10, ABG, iCa and lactate. 

TEG/TEM (thromboelastography, -metry )are excellent methods of quickly assessing and monitoring coagulation status. Monitor every 4-6 units of RBCs.

For antifibrinolytic therapy in adults, administer tranexamic acid 1g IV bolus and consider a second 1g bolus or sustained drip. 

To avoid dilution minimize the use of crystalloid and colloid therapy.

Joe Nemeth | Nisreen Hamza-Maghraby


Popular posts from this blog

Ketamine: The Past, Present, and Potential Future of an Anesthetic Drug

Ketamine is a powerful anesthetic drug that has been used in medical settings for decades. However, its effects on the brain have also led to its use as a recreational drug, leading to controversy surrounding its use. Despite its negative associations, recent research has shown promising potential for the drug in the treatment of mental health conditions such as depression and post-traumatic stress disorder (PTSD).
Read more

Fast track anesthesia approaches

  Fast track anesthesia schemes are multi-modal approaches that aim to reduce the physiological stress response to surgery, enhance recovery, and improve patient outcomes. These schemes typically involve several aspects of perioperative care, including anesthesia management, surgical technique, pain management, fluid management, and early mobilization. Here are some common fast track anesthesia schemes:
Read more