27th May 2023

Major Haemorrhage

Management of major haemorrhage

Major haemorrhage is bleeding which is life-threatening. A number of definitions exist, based on quantifying the volume or blood lost, but in the clinical setting major haemorrhage is best recognised as bleeding with haemodynamic instability.

• Loss of more than one blood volume within 24 hours (around 70 mL/kg which is >5 litres in a 70 kg adult)
• 50% of total blood volume lost in less than 3 hours
• Bleeding in excess of 150 mL/minute
• Bleeding with haemodynamic instability (heart rate >110 or systolic blood pressure <90mmHg).

It is critical that the source of bleeding is addressed. Meanwhile, massive transfusion is required to maintain vital organ transfusion. Hospital Major Haemorrhage Protocols ensure timely and appropriate provision of blood product resuscitation. The transfusion of large volumes of red cells with no coagulation factor or platelet replacement causes dilutional coagulopathy. Therefore, in a major haemorrhage shock-pack, pre-defined ratios of blood components are provided by the laboratory, which includes packed red cells, FFP and platelets. Peripheral blood haematocrit and Hb concentration may be misleading in early major blood loss and the decision to transfuse should be based on clinical criteria and observations.

Immediate priorities:

1. Resuscitation and early communication with the laboratory through a 2222 major haemorrhage alert
2. Baseline FBC, clotting screen and crossmatch
3. Control bleeding (may need to involve surgeons and interventional radiology) and consider early administration of anti-fibrinolytics such as tranexamic acid
4. Maintain organ perfusion through transfusion of blood and other fluids
5. Initially use Group O red cells. If female and <50 years old, then they should receive RhD negative red cells to avoid sensitisation.
6. Once available use group-specific blood.
7. Typically for 6 units of packed red cells: 4 units of FFP, 2 pools of cryoprecipitate and 1 adult therapeutic dose of platelets should be administered.
8. Once laboratory results are available this can be better tailored. For example: if the Hb is falling, give red cells; if the prothrombin time ratio is >1.5, then give FFP; if fibrinogen <1.5g/L, then give cryoprecipitate 2 pools; if platelets <75 x10⁹/L, then give 1 adult therapeutic dose.
9. In certain cases vitamin K, desmopressin, PCC, activated PCC (FEIBA™), recombinant factor concentrates (such as NovoSeven™) or specific direct oral anticoagulant (DOAC) reversal therapy may be indicated and must always involve a discussion with a haematologist.
10. Sometimes a principle of ‘damage control resuscitation’ is used with permissive hypotension to minimise secondary blood loss

Tranexamic acid reduces blood transfusion in patients undergoing emergency or urgent surgery in a Cochrane review (2012) and the risk of death in bleeding trauma patients in CRASH-2 trial (2010) and bleeding post-partum haemorrhage patients in WOMAN trial (2017). However, in the HALT-IT trial (2020) analysing the use of tranexamic acid in gastrointestinal bleeding, it did not reduce death and thromboembolic events were found to be higher. This is possibly because it is challenging in gastrointestinal bleeding to determine the age of the bleeding and the benefit from tranexamic acid comes in early administration to reduce fibrinolysis.