What is the treatment for vascular hemorrhage?

Treatment of Vascular Hemorrhage

The immediate control of obvious bleeding is of paramount importance in vascular hemorrhage management, using direct pressure, tourniquets, or hemostatic dressings as first-line interventions. 1, 2

Initial Assessment and Management

• Assess the extent of hemorrhage using an established clinical grading system to determine severity and guide treatment approach 1
• Patients with hemorrhagic shock and identified bleeding source should undergo immediate bleeding control procedures unless initial resuscitation measures are successful 1
• Patients with unidentified bleeding sources require immediate further assessment including focused sonography (FAST) for detection of free fluid in suspected torso trauma 1
• Mobilize hospital's major hemorrhage protocol immediately when massive hemorrhage is declared 1

Immediate Hemorrhage Control Techniques

• Apply direct pressure to bleeding sites as the most effective initial intervention 3
• For extremity hemorrhage, consider tourniquet application if direct pressure is ineffective 2
• Use hemostatic dressings for wounds with significant bleeding that cannot be controlled with direct pressure alone 2
• Elevate and immobilize bleeding extremities as an adjunctive measure when used with direct pressure 3

Surgical and Interventional Management

• For patients with significant intraabdominal fluid and hemodynamic instability, urgent surgery is indicated 1
• Employ damage control surgery for severely injured patients with deep hemorrhagic shock, ongoing bleeding, coagulopathy, hypothermia, and acidosis 1
• Use packing, direct surgical bleeding control, and local hemostatic procedures for early bleeding control 1
• Consider aortic cross-clamping as an adjunct bleeding control measure in exsanguinating patients 1
• For pelvic ring disruption with hemorrhagic shock, perform immediate pelvic ring closure and stabilization 1
• Patients with ongoing hemodynamic instability despite adequate pelvic ring stabilization should receive early angiographic embolization or surgical bleeding control 1, 4

Blood Product Administration and Coagulopathy Management

• Administer blood products in a 1:1:1 ratio (RBC:FFP:platelets) for severely traumatized patients 2
• Begin with early FFP administration (15 ml/kg) to prevent dilutional coagulopathy 1
• For established coagulopathy (fibrinogen <1 g/L or PT/aPTT >1.5× normal), administer more than 15 ml/kg of FFP 1
• Target a minimum platelet count of 75 × 10^9/L 1, 2
• Consider antifibrinolytic agents such as tranexamic acid (10-15 mg/kg followed by infusion of 1-5 mg/kg/h) 1, 5
• Use fibrinogen concentrate or cryoprecipitate for rapid fibrinogen replacement when levels are low 1

Fluid Resuscitation and Hemodynamic Goals

• Initially use crystalloids for fluid therapy; colloids may be added within prescribed limits 1
• Target a systolic blood pressure of 80-100 mmHg until major bleeding has been stopped in trauma patients without brain injury (permissive hypotension) 1
• Avoid hyperventilation or excessive positive end-expiratory pressure in severely hypovolemic trauma patients 1

Monitoring and Ongoing Assessment

• Monitor serum lactate and base deficit to estimate and track the extent of bleeding and shock 1
• Do not rely on single hematocrit measurements as isolated markers for bleeding 1
• Use CT for further assessment in hemodynamically stable patients with suspected head, chest, or abdominal bleeding following high-energy injuries 1

Post-Resuscitation Care

• Commence standard venous thromboprophylaxis as soon as hemostasis is secured, as patients develop a prothrombotic state following massive hemorrhage 1, 2
• Monitor for and correct electrolyte abnormalities, particularly hypocalcemia from citrate toxicity 2

Common Pitfalls to Avoid

• Delaying activation of the massive transfusion protocol can increase mortality; activate early when massive hemorrhage is anticipated 2
• Waiting for laboratory results before administering blood products in obvious massive hemorrhage increases mortality 2
• Using O-negative blood when it's not immediately needed; group-specific blood can be issued without antibody screening 1