From the Research
Major haemorrhage is classified as blood loss exceeding 150 ml/minute or 50% of blood volume within 3 hours, or blood loss leading to a systolic blood pressure below 90 mmHg or heart rate above 110 beats per minute, according to the most recent and relevant guidelines. The classification also includes situations where a patient has lost more than 40% of their blood volume (approximately 2 liters in an average adult) or when there is ongoing uncontrolled bleeding 1.
Key Points to Consider
- Major haemorrhage requires immediate activation of a major haemorrhage protocol, which involves administering blood products in a 1:1 ratio of packed red cells and fresh frozen plasma, until the results of coagulation tests are available 1.
- Initial management includes securing large-bore intravenous access (at least 16G), administering tranexamic acid 1g intravenously within 3 hours of bleeding onset (followed by 1g over 8 hours), and maintaining normothermia 2.
- Point-of-care testing should be used to guide further blood product administration, and fibrinogen levels should be maintained > 2 g.l-1 in postpartum haemorrhage and > 1.5 g.l-1 in other haemorrhage 1.
- The protocol emphasizes early communication between clinical teams, laboratory services, and blood banks to ensure rapid delivery of blood products, which is crucial because major haemorrhage accounts for significant mortality, and outcomes improve with rapid recognition and structured management approaches that address both blood loss and the developing coagulopathy 1.
Management Approach
- 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 1.
- Recent trial data advocate for a more personalised approach depending on the clinical scenario, and improving outcomes after major traumatic haemorrhage is now driving research to include extending blood-product resuscitation into prehospital care 1.