What is the immediate management of hemorrhage?

Immediate Management of Hemorrhage

The immediate management of hemorrhage requires direct pressure to the bleeding site, followed by a high-ratio transfusion strategy with at least 1 unit plasma per 2 units RBCs (approaching a 1:1:1 ratio of RBC:plasma:platelets), and early administration of tranexamic acid with a loading dose of 1g over 10 minutes followed by 1g over 8 hours. 1, 2

Initial Hemorrhage Control

1. Direct pressure application:

   • Apply firm, direct pressure to the bleeding site - most effective immediate intervention 3
   • For extremity bleeding, elevate and immobilize the affected limb while maintaining pressure 3
   • If direct pressure is ineffective, consider wound packing with hemostatic dressings 4

2. Laboratory assessment:

   • Obtain baseline blood tests including:
     • Complete blood count
     • Prothrombin time (PT)
     • Activated partial thromboplastin time (aPTT)
     • Clauss fibrinogen
     • Type and cross-match 1
   • Repeat coagulation tests every 30-60 minutes during active bleeding 1

Blood Product Transfusion Strategy

1. Platelet transfusion targets:

   • Maintain minimum platelet count of 75 × 10⁹/L for significant hemorrhage
   • Target 50 × 10⁹/L for patients with significant bleeding
   • Target 100 × 10⁹/L for patients with multiple trauma or traumatic brain injury 1
   • Initial dose: 4-8 platelet concentrates or one apheresis pack 1

2. Plasma and RBC transfusion:

   • Implement high-ratio transfusion strategy (at least 1 unit plasma per 2 units RBCs)
   • Aim for 1:1:1 ratio (RBC:plasma:platelets) for massive bleeding 1, 2

3. Fibrinogen replacement:

   • Maintain fibrinogen levels >1.5 g/L using cryoprecipitate or fibrinogen concentrate
   • For postpartum hemorrhage, maintain fibrinogen >2 g/L 1, 2
   • Administer cryoprecipitate when fibrinogen levels are <1.5 g/L 1

Pharmacological Interventions

1. Tranexamic acid (TXA):

   • Administer if evidence of hyperfibrinolysis or in major trauma/postpartum hemorrhage
   • Dosing: 1g loading dose over 10 minutes, followed by 1g over 8 hours 1, 2
   • Contraindications:
     • Subarachnoid hemorrhage (risk of cerebral edema and infarction)
     • Active intravascular clotting
     • Severe hypersensitivity to TXA 5
   • Note: TXA is not recommended for gastrointestinal bleeding 2

2. Prothrombin Complex Concentrate (PCC):

   • Primarily indicated for urgent reversal of vitamin K antagonists 1

Monitoring Parameters

1. Coagulation targets:

   • PT/aPTT: maintain <1.5 times normal
   • Fibrinogen: >1.5 g/L (>2 g/L for postpartum hemorrhage)
   • Platelet count: >75 × 10⁹/L 1, 2

2. Complications to monitor:

   • Rebleeding (associated with high mortality)
   • Transfusion-Related Acute Lung Injury (TRALI)
   • Transfusion-Associated Circulatory Overload (TACO)
   • Metabolic derangements
   • Hypothermia
   • Citrate toxicity 1

Special Considerations

1. Massive hemorrhage definition:

   • Loss of one blood volume within a 24-hour period 1

2. Avoid the lethal triad:

   • Hypothermia
   • Acidemia
   • Coagulopathy 2

3. Definitive control:

   • Early surgical intervention or interventional radiology for definitive hemostasis 2, 3
   • Recognize that temporizing measures are bridges to definitive care 6

4. Caution with tourniquets:

   • While effective for extremity hemorrhage in humans, evidence for use in smaller patients is limited 3
   • Avoid circumferential compressive bandages that are too tight around neck, thorax, or abdomen as they may compromise airway or respiration 3

The immediate management of hemorrhage requires rapid recognition and intervention with a systematic approach to control bleeding and restore hemostasis while avoiding complications of the lethal triad.