Initial Management of Life Threatening Haemorrhage

Life-threatening haemorrhage is bleeding that threatens life within minutes to hours: loss of a large volume, bleeding with shock, or bleeding into a critical site. Death from haemorrhage is mostly preventable if the bleeding is recognised early, the source is controlled and blood and tranexamic acid are given promptly. Delay, large crystalloid volumes, cold, acidosis and uncorrected coagulopathy kill.

Mechanisms. Trauma, obstetric (postpartum, antepartum, ruptured ectopic), gastrointestinal (varices, ulcers), surgical, ruptured aneurysm, and bleeding on anticoagulants.

Risk context. Compensation hides shock until late, especially in young adults, children and pregnant women. Beta blockers and older age blunt tachycardia. Haemoglobin is normal early.

Special groups. Pregnancy and postpartum (blood volume expansion, rapid collapse), children (late hypotension), older adults, patients on anticoagulants or antiplatelet drugs, and patients with liver disease. In East Africa, delay in reaching a hospital, limited blood stock, and limited availability of plasma, platelets and surgical capacity are common, so early referral, early transfusion and local resource planning save lives.

Recognition.

• Heart rate, blood pressure, capillary refill, mental state, respiratory rate and urine output.

• Shock index (heart rate divided by systolic blood pressure): a value of about 0.9 to 1 or more predicts significant bleeding and need for transfusion.

• Estimated blood loss: obstetric loss over 1000 mL, or any loss with signs of shock, is major haemorrhage.

• Source: external, chest, abdomen, pelvis, long bones, retroperitoneum, uterus, gastrointestinal tract.

Criteria for activating the massive haemorrhage plan.

• Bleeding with systolic blood pressure under 90 mmHg or heart rate over 120 beats a minute not responding to a small crystalloid bolus.

• Estimated blood loss over 150 mL/minute, or one blood volume in 24 hours, or half a blood volume in 3 hours.

• Trauma scoring that predicts massive transfusion (for example penetrating mechanism, positive focused ultrasound, systolic pressure of 90 mmHg or less, heart rate of 120 or more, with two or more positive indicating high risk).

• Clinician judgement of ongoing life-threatening bleeding.

Laboratory use. Send group and crossmatch, full blood count, coagulation screen, fibrinogen, blood gas with lactate, ionised calcium and potassium, but do not wait for results before resuscitation.

Differential considerations. Non-haemorrhagic shock (sepsis, cardiogenic, obstructive, neurogenic, anaphylactic), which may coexist with bleeding.

Red flags. Penetrating torso injury, pelvic fracture, ruptured ectopic pregnancy, placental abruption, uterine atony, varices, aortic aneurysm, anticoagulant use, cold, acidosis and ongoing hypotension.

First minutes, in parallel.

1. Call for senior help and activate the massive haemorrhage plan if criteria are met.

2. Control the source: direct pressure, tourniquet for limb bleeding, pelvic binder, haemostatic dressing, surgical or radiological control, uterine measures (massage, uterotonics, balloon tamponade, surgery), endoscopic control, and early transfer.

3. Secure airway, give oxygen, and obtain two large bore intravenous lines or intraosseous access.

4. Take samples, and request emergency blood.

5. Give tranexamic acid 1 g intravenously over 10 minutes within 3 hours of injury or birth, then 1 g over 8 hours in trauma. In postpartum haemorrhage, a second 1 g dose may be given if bleeding continues after 30 minutes.

6. Keep the patient warm, and use warmed fluids and products.

Fluids and blood. Avoid large volumes of crystalloid. Give red cells or whole blood early and plasma and platelets in balanced proportions in massive haemorrhage, directed by clinical response and by laboratory or viscoelastic results. Give calcium (for example calcium chloride 10 mL of 10% intravenously, repeated to keep ionised calcium at or over about 1.1 mmol/L) when many units are given. Replace fibrinogen when it falls under 1.5 g/L (under 2 g/L in postpartum haemorrhage).

Blood pressure. Permissive hypotension (systolic 80 to 90 mmHg) until bleeding is controlled, except in head or spinal injury and pregnancy, where higher targets are needed.

Reversal of anticoagulants. Prothrombin complex concentrate with vitamin K for vitamin K antagonists, specific reversal agents for direct oral anticoagulants where available, and protamine for heparin.

Special groups.

• Pregnancy: left lateral tilt, early obstetric intervention, early fibrinogen replacement, and tranexamic acid.

• Children: 10 to 20 mL/kg of red cells or 20 mL/kg of whole blood, repeated as needed.

• Older adults: avoid overload, and recognise blunted responses.

• Jehovah's Witnesses and others refusing blood: all other measures, early senior input and documented decisions.

Monitoring. Continuous heart rate, blood pressure, oxygen saturation, temperature and urine output. Repeat blood gas, lactate, haemoglobin, ionised calcium, potassium, platelets, coagulation and fibrinogen every 30 to 60 minutes during active bleeding.

Complications. Hypothermia, acidosis, hypocalcaemia, hyperkalaemia, dilutional coagulopathy, transfusion associated lung injury and overload, and multi organ failure.

Referral and escalation. Surgeon, anaesthetist, intensivist, obstetrician, haematologist and blood bank medical lead early. Transfer to a centre with surgical and blood capacity as soon as the patient can be safely moved, with the resuscitation continuing.

Disposition. After bleeding is controlled, transfer to high dependency or intensive care. Stop the massive haemorrhage plan, return unused products, and treat anaemia, coagulopathy and the cause. Record all products given.