What is the treatment for acute heavy bleeding?

Management of Acute Heavy Bleeding

The immediate treatment for acute heavy bleeding should include rapid assessment of bleeding source, hemodynamic stabilization with crystalloids, early administration of tranexamic acid (1g over 10 minutes followed by 1g over 8 hours), and implementation of a balanced transfusion strategy approaching a 1:1:1 ratio (RBC:plasma:platelets) for massive hemorrhage. 1, 2

Initial Assessment and Stabilization

• Rapid clinical assessment:

  • Evaluate visible blood loss (on clothes, floor, drains)
  • Check for signs of internal bleeding
  • Assess vital signs (heart rate, blood pressure, capillary refill, skin color, consciousness)
  • Look for injury patterns that suggest major bleeding sources 2

• Hemodynamic stabilization:

  • Establish large-bore IV access (at least 2 lines)
  • Begin crystalloid resuscitation (avoid saline) 2
  • Target systolic blood pressure of 80-100 mmHg until bleeding is controlled 2
  • Avoid excessive positive end-expiratory pressure in ventilated patients 2

Immediate Interventions

Medications

1. Tranexamic acid:

   • Administer 1g IV over 10 minutes, followed by 1g over 8 hours 2, 1
   • Most effective when given early in the bleeding course
   • Contraindicated in subarachnoid hemorrhage and active intravascular clotting 3
   • Monitor for potential adverse effects (seizures, hypersensitivity reactions) 3

2. Blood product administration:

   • Implement balanced transfusion strategy approaching 1:1:1 ratio (RBC:plasma:platelets) 1
   • Early administration of fresh frozen plasma (FFP) at 10-15 ml/kg 2
   • Target parameters:
     • Fibrinogen >1.5 g/L using cryoprecipitate or fibrinogen concentrate
     • Platelet count >75 × 10⁹/L
     • PT/APTT <1.5 times normal 1

Procedural Interventions

1. Source identification:

   • Focused assessment with sonography for trauma (FAST) for suspected torso trauma 2
   • CT imaging for hemodynamically stable patients with suspected head, chest, or abdominal bleeding 2
   • Direct visualization of bleeding site when possible

2. Bleeding control:

   • Direct pressure for external bleeding
   • Packing, direct surgical control, and local hemostatic procedures for surgical bleeding 2
   • Damage control surgery for severely injured patients with deep hemorrhagic shock 2
   • Pelvic ring closure and stabilization for patients with pelvic ring disruption 2
   • Angiographic embolization for ongoing instability despite other measures 2

Ongoing Management

• Monitoring:

  • Regular laboratory assessment: hemoglobin, platelet count, PT, aPTT, fibrinogen levels
  • Repeat coagulation tests every 30-60 minutes during active bleeding 1
  • Monitor for rebleeding and complications of massive transfusion

• Correction of physiologic derangements:

  • Actively warm patient to prevent hypothermia
  • Correct acidosis
  • Monitor and treat hypocalcemia from citrate toxicity during massive transfusion 2

• Specific bleeding scenarios:

  • For esophageal variceal bleeding: endoscopic band ligation 4
  • For gastric variceal bleeding: endoscopic cyanoacrylate injection when available 4
  • For heavy menstrual bleeding: hormonal treatments (LNG-IUS, combined hormonal contraceptives) and tranexamic acid 5

Common Pitfalls and Caveats

1. Avoid over-resuscitation with fluids before bleeding is controlled, as this may worsen bleeding through increased blood pressure and dilutional coagulopathy 6

2. Don't delay tranexamic acid administration - efficacy decreases significantly when given later in the course of bleeding 2

3. Be aware of contraindications to tranexamic acid including subarachnoid hemorrhage, active intravascular clotting, and history of hypersensitivity 3

4. Consider underlying bleeding disorders in patients with disproportionate bleeding, especially in cases of heavy menstrual bleeding where up to 20% may have an inherited bleeding disorder 5

5. Monitor for transfusion-related complications including Transfusion-Related Acute Lung Injury (TRALI), Transfusion-Associated Circulatory Overload (TACO), and metabolic derangements 1

By following this structured approach to acute heavy bleeding, focusing on early identification, rapid intervention with tranexamic acid, balanced blood product administration, and definitive bleeding control, you can significantly improve patient outcomes in terms of morbidity and mortality.