What is the classification of major hemorrhage?

From the Guidelines

Major hemorrhage is classified into four types based on the severity of blood loss and its impact on the patient's physiological status, with Type 1 being the least severe and Type 4 being the most severe, leading to death 1. The classification of major hemorrhage is crucial in guiding resuscitation efforts and preventing morbidity and mortality.

• Type 1 hemorrhage involves overt bleeding that does not require surgical or percutaneous intervention, but does require medical intervention by a healthcare professional, leading to hospitalization, an increased level of care, or medical evaluation.
• Type 2 hemorrhage requires a transfusion of 2–4 units of whole blood/red blood cells or is associated with a haemoglobin drop of >3 g/dL but <5 g/dL.
• Type 3 hemorrhage involves overt bleeding in a critical organ, such as intracranial, intraspinal, intraocular, pericardial, or intramuscular with compartment syndrome, or causes hypovolemic shock or severe hypotension.
• Type 4 hemorrhage leads to death, which can be classified as probable or definite based on clinical suspicion or confirmation by autopsy or imaging 1. The most recent and highest quality study, published in 2021, provides a comprehensive classification system for major hemorrhage, emphasizing the importance of timely and appropriate management to prevent morbidity and mortality 1. Key factors in the management of major hemorrhage include recognition, communication, timely delivery of blood products, and application of definitive modalities of treatment, such as surgery and interventional radiology 1. The classification of major hemorrhage should be based on the most recent and highest quality evidence, which prioritizes the severity of blood loss and its impact on the patient's physiological status 1.

From the Research

Classification of Major Haemorrhage

• Major haemorrhage is a leading cause of morbidity and mortality worldwide, often accompanied by volume loss, haemodilution, acidaemia, hypothermia, and coagulopathy 2
• The management of major haemorrhage has evolved to deliver a 'package' of haemostatic resuscitation, including surgical or radiological control of bleeding, regular monitoring of haemostasis, advanced critical care support, and avoidance of the lethal triad of hypothermia, acidaemia, and coagulopathy 2

Resuscitation Fluids

• The selection and use of resuscitation fluids may affect the outcomes of patients, but the optimal resuscitative fluid remains controversial 3
• Studies have compared the effects of different resuscitation fluids, including normal saline, lactated Ringer's solution, hypertonic saline, and colloids, on physiological, biochemical, and organ functions following hemorrhagic shock 4, 5, 6
• The use of balanced crystalloids versus normal saline in critically ill patients has been systematically reviewed, with results showing no significant difference in mortality, but potential benefits of balanced crystalloids in patients with non-traumatic brain injury 3

Haemostatic Resuscitation

• Haemostatic resuscitation, including the use of fresh frozen plasma, tranexamic acid, and fibrinogen, has been advocated for in the management of major haemorrhage 2
• The goal of haemostatic resuscitation is to restore the balance of coagulation and prevent the development of coagulopathy, which is a major contributor to morbidity and mortality in major haemorrhage 2