From the Guidelines
Bleeding can be categorized into several types, including arterial, venous, capillary, internal, and external bleeding, each requiring specific management approaches, with the most recent guidelines from the American College of Cardiology (1) emphasizing the importance of assessing bleed severity and managing major and non-major bleeds accordingly.
Types of Bleeding
- Arterial bleeding: bright red and pulsatile
- Venous bleeding: darker and flows steadily
- Capillary bleeding: slow and oozing
- Internal bleeding: occurs inside the body
- External bleeding: visible outside the body
Management of Bleeding
- Direct pressure on the wound using clean cloth or gauze for 15-20 minutes
- For severe bleeding, apply a tourniquet above the wound if on a limb, marking the time of application
- Elevation of the bleeding site above heart level can help reduce blood flow
- Hemostatic agents like QuikClot or Celox can be applied directly to wounds
- Tranexamic acid (TXA) at 1g IV over 10 minutes followed by 1g over 8 hours can be administered for major trauma within 3 hours, as recommended by the European Heart Rhythm Association (1)
- Volume replacement with isotonic crystalloids like normal saline at 1-2 liters initially may be necessary for significant blood loss
- Bleeding disorders may require specific factor replacements or medications like desmopressin (DDAVP) at 0.3 mcg/kg for mild hemophilia or von Willebrand disease
Assessment of Bleed Severity
- The BARC (Bleeding Academic Research Consortium) definitions of bleeding (1) provide a standardized framework for assessing bleed severity, categorizing bleeding into types 0-5 based on the presence of overt bleeding, hemoglobin drop, and need for transfusion or surgical intervention.
- The 2020 ACC Expert Consensus Decision Pathway on Management of Bleeding in Patients on Oral Anticoagulants (1) provides guidance on assessing bleed severity and managing major and non-major bleeds, including the use of reversal agents and supportive care.
From the Research
Types of Bleeding
- Trauma 2
- Gastrointestinal bleeding 2
- Haemoptysis 2
- Intracranial haemorrhage 2
- Haemophilia A [(3,4,5)]
- Acquired haemophilia A 4
Management of Bleeding
- Aggressive resuscitation 2
- Haemodynamic stabilization 2
- Repletion of volume and blood loss 2
- Reversal of coagulopathy 2
- Identification of the source of bleeding 2
- Use of tranexamic acid (TXA) [(3,4,5)]
- Use of recombinant factor VIII (rFVIII) [(3,5)]
- Use of activated prothrombin complex concentrate (APCC) 4
- Tourniquets 6
- Hemostatic dressings 6
- Direct manual pressure 6
Treatment Outcomes
- Improved clot stability with TXA and rFVIII 3
- Improved hemostatic response with APCC and TXA 4
- Decreased mortality with tourniquets compared to direct manual pressure 6
- Shorter time to hemostasis with hemostatic dressings compared to direct manual pressure 6
- Decreased joint bleeding with TXA and rFVIII in prophylactic setting 5