Management Protocol for Massive Bleeding
The cornerstone of managing massive hemorrhage is immediate implementation of a structured major hemorrhage protocol that includes rapid control of bleeding, early blood product administration in a 1:1:1 ratio (RBC:FFP:platelets), and aggressive correction of coagulopathy to reduce mortality.1
Initial Actions
- Immediately control obvious bleeding through direct pressure, tourniquets, or hemostatic dressings 1
- Administer high FiO2 and secure large-bore IV access (including central access if needed) 1
- Obtain baseline laboratory tests: FBC, PT, aPTT, Clauss fibrinogen, and cross-match 1
- If available, use near-patient testing (TEG or ROTEM) to guide therapy 1, 2
- Initiate fluid resuscitation with warmed blood products (O negative initially if cross-matched blood unavailable) 1
- Actively warm the patient and all transfused fluids to prevent hypothermia 1
- Alert surgical teams and mobilize resources for definitive hemorrhage control 1
Blood Product Administration
- Administer blood products in a 1:1:1 ratio of RBC:FFP:platelets for severely injured patients with massive bleeding 1, 2
- Begin with early FFP administration at 10-15 ml/kg to prevent dilutional coagulopathy 1
- Maintain a minimum platelet count of 75 × 10^9/L 1
- For established coagulopathy (fibrinogen <1 g/L or PT/aPTT >1.5× normal), administer more than 15 ml/kg of FFP 1
- Rapidly replace fibrinogen using fibrinogen concentrate or cryoprecipitate when fibrinogen levels are low 1
Ongoing Assessment and Management
- Continuously assess for signs of ongoing bleeding (visible blood loss, hemodynamic instability) 1
- Perform early imaging (ultrasound, CT) or surgery as appropriate for definitive hemorrhage control 1
- Consider cell salvage autotransfusion when appropriate 1
- Once bleeding is controlled, normalize blood pressure, acid-base status, and temperature 1
- Avoid vasopressors during active hemorrhage 1
- Monitor coagulation parameters, hemoglobin, and blood gases regularly 1
Management of Coagulopathy
- Anticipate and prevent coagulopathy rather than treating it after it develops 3
- For dilutional coagulopathy, administer FFP early in the resuscitation 1
- For consumptive coagulopathy, more aggressive component therapy may be required 1
- Target fibrinogen levels >1 g/L using fibrinogen concentrate or cryoprecipitate 1
- Consider TEG/ROTEM to guide specific component therapy 2, 4
Post-Resuscitation Care
- Admit to critical care for ongoing monitoring and management 1
- Initiate standard venous thromboprophylaxis as soon as hemostasis is secured, as patients rapidly develop a prothrombotic state 1
- Consider temporary inferior vena cava filtration in high-risk patients 1
- Continue to monitor for delayed bleeding and coagulopathy 1
Common Pitfalls and Caveats
- Delaying activation of the massive transfusion protocol can increase mortality; activate early when massive hemorrhage is anticipated 1
- Using crystalloids alone for volume resuscitation worsens dilutional coagulopathy 5
- Failing to warm blood products and the patient leads to hypothermia, which worsens coagulopathy 5
- Waiting for laboratory results before administering blood products in obvious massive hemorrhage increases mortality 1, 2
- Group O negative blood should only be used when blood is needed immediately; switch to group-specific blood as soon as possible 1
- Overlooking the development of hypocalcemia during massive transfusion can lead to cardiac dysfunction 1
Special Considerations
- For trauma patients, damage control surgery may be necessary before complete physiologic normalization 1
- In hospitals with frequent massive transfusion needs, pre-prepared "shock packs" can improve efficiency 1
- The use of recombinant Factor VIIa should be limited to specific situations after standard therapies have failed, due to thrombotic risk 6
- Monitor for and correct electrolyte abnormalities, particularly hypocalcemia from citrate toxicity 1, 5