What are the management options for subchronic hemorrhage?

Management of Subchronic Hemorrhage

The management of subchronic hemorrhage requires immediate assessment of the bleeding source, rapid control of obvious bleeding points, and implementation of a systematic approach to restore hemodynamic stability while preventing coagulopathy.

Initial Assessment and Stabilization

• Control obvious bleeding points using direct pressure, tourniquets, or hemostatic dressings 1
• Administer high FiO2 and establish large-bore IV access 1
• Obtain baseline laboratory tests:
  • Complete blood count (CBC)
  • Prothrombin time (PT) and activated partial thromboplastin time (aPTT)
  • Clauss fibrinogen (not derived fibrinogen)
  • Blood typing and cross-matching 1
• If available, perform near-patient testing (thromboelastography or thromboelastometry) 1
• Assess for:
  • Visible blood loss
  • Signs of internal bleeding
  • Vital signs and perfusion status 1

Diagnostic Evaluation

• Early focused sonography (FAST) for detection of free fluid in suspected torso trauma 1
• CT imaging for hemodynamically stable patients with suspected head, chest, or abdominal bleeding 1
• Monitor serum lactate and base deficit to estimate and monitor extent of bleeding and shock 1
• Single hematocrit measurements should not be used as an isolated marker for bleeding 1

Fluid Resuscitation and Blood Product Administration

• Use warmed blood products and fluids 1
• Target systolic blood pressure of 80-100 mmHg until major bleeding is controlled (in patients without brain injury) 1
• Initial fluid therapy with crystalloids; colloids may be added within prescribed limits 1
• For massive hemorrhage, implement high-ratio transfusion strategy (at least 1 unit of plasma per 2 units of RBCs) 2
• Maintain fibrinogen levels >1.5 g/L and platelet count >75 × 10⁹/L 2
• Consider antifibrinolytic agents:
  • Tranexamic acid: 10-15 mg/kg followed by infusion of 1-5 mg/kg/h
  • ε-aminocaproic acid: 100-150 mg/kg followed by 15 mg/kg/h 1

Surgical and Interventional Management

• Patients with identified bleeding source and hemodynamic instability should undergo immediate bleeding control procedure 1
• For pelvic ring disruption with hemorrhagic shock, perform immediate pelvic ring closure and stabilization 1
• Consider angiographic embolization or surgical bleeding control for ongoing instability despite adequate pelvic stabilization 1
• Early bleeding control techniques include:
  • Packing
  • Direct surgical control
  • Local hemostatic procedures
  • Aortic cross-clamping (as adjunct in exsanguinating patients) 1
• Damage control surgery for severely injured patients with deep hemorrhagic shock, ongoing bleeding, coagulopathy, hypothermia, or acidosis 1

Special Considerations for Specific Types of Subchronic Hemorrhage

Chronic Subdural Hematoma

• Reverse anticoagulant/antiplatelet therapies
• Consider anti-epileptic drugs
• Surgical intervention (twist-drill craniostomy, burr-hole craniostomy, or craniotomy) if imaging shows compression (>1 cm thickness) or patient is symptomatic 3

Subchorionic Hemorrhage (Second and Third Trimesters)

• Monitor with serial growth ultrasounds
• Consider umbilical artery Doppler studies and antenatal fetal testing, particularly for large hemorrhages 4

Post-Treatment Care

• Admit to critical care for monitoring after treatment for massive hemorrhage 1
• Regularly monitor coagulation parameters, hemoglobin, and blood gases 1
• Actively warm the patient to prevent hypothermia 1
• Correct hypocalcemia and hypomagnesemia, which are common with massive transfusions 2
• Initiate standard venous thromboprophylaxis as soon as bleeding is controlled 1
• Consider temporary inferior vena cava filtration in high-risk cases 1

Contraindications and Precautions

• Tranexamic acid is contraindicated in patients with:
  • Subarachnoid hemorrhage (risk of cerebral edema and infarction)
  • Active intravascular clotting
  • Hypersensitivity to tranexamic acid 5
• Avoid concomitant use of tranexamic acid with pro-thrombotic medical products 5

Monitoring for Complications

• Watch for recurrent hemorrhage (occurs in 10-20% of chronic subdural hematoma cases) 3
• Monitor for thromboembolic events, especially when using antifibrinolytic agents 5
• Be alert for seizures, hypersensitivity reactions, and visual disturbances with tranexamic acid use 5

The time elapsed between injury and definitive intervention should be minimized to improve outcomes 1. A well-defined hospital protocol for managing massive hemorrhage should be in place to facilitate communication and timely delivery of blood products 2.