What is the initial approach to managing a patient with hemorrhagic diathesis?

Initial Management of Hemorrhagic Diathesis

The immediate priority is to control active bleeding through direct pressure, tourniquets, or hemostatic dressings while simultaneously securing large-bore IV access and initiating resuscitation with warmed blood products rather than crystalloid. 1

Immediate Actions (First 15 Minutes)

Hemorrhage Control and Airway Management

• Apply direct pressure, tourniquets, or hemostatic dressings to all visible bleeding sites 1
• Secure airway and administer high FiO2, particularly if the patient has altered consciousness 1, 2
• Establish the largest bore IV access possible, ideally including central venous access 1, 2

Rapid Clinical Assessment

• If the patient is conscious, talking, and has a palpable peripheral pulse, blood pressure is adequate for the moment 1
• Assess for obvious blood loss (on clothing, floor, drains) and signs of internal bleeding 1
• Evaluate physiology: skin color, heart rate, capillary refill, and conscious level 1

Initial Laboratory Evaluation

• Draw baseline labs immediately: complete blood count, PT, aPTT, Clauss fibrinogen (not derived fibrinogen), and cross-match 1, 2
• Obtain near-patient testing with thromboelastography (TEG) or thromboelastometry (ROTEM) if available 1
• Measure serum lactate and base deficit to estimate bleeding severity 1

Resuscitation Strategy

Blood Product Administration

Begin fluid resuscitation with warmed blood and blood components, not crystalloid 1. The most recent European trauma guidelines (2023) recommend two initial strategies 1:

• Option 1: Fibrinogen concentrate or cryoprecipitate plus packed red blood cells
• Option 2: Fresh frozen plasma (FFP) with packed red blood cells in a ratio of at least 1:2 (FFP:pRBC)

Use blood group O initially for fastest availability, followed by group-specific, then cross-matched blood 1

Temperature Management

• Actively warm the patient and all transfused fluids to prevent hypothermia-induced coagulopathy 1, 2

Blood Pressure Targets

• Target systolic blood pressure of 80-100 mmHg until bleeding is controlled in patients without brain injury 1
• Avoid vasopressors during active bleeding 1
• Restore organ perfusion without achieving normal blood pressure initially 1

Goal-Directed Coagulation Management

Fibrinogen Replacement

Administer initial fibrinogen supplementation of 3-4 g fibrinogen concentrate or 15-20 single donor units of cryoprecipitate 1. Repeat doses should be guided by viscoelastic monitoring and laboratory fibrinogen levels 1.

Fresh Frozen Plasma

• Use FFP for PT/aPTT >1.5 times normal or viscoelastic evidence of coagulation factor deficiency 1, 2
• Avoid FFP solely for hypofibrinogenemia correction 1

Platelet Transfusion

• Maintain platelet count above 50 × 10⁹/L in ongoing bleeding 1
• Maintain platelet count above 75-100 × 10⁹/L in traumatic brain injury 1, 2
• Administer 4-8 single platelet units or one apheresis pack initially 1

Antifibrinolytic Therapy

Administer tranexamic acid 1 g over 10 minutes as soon as possible (ideally en route to hospital), followed by 1 g infused over 8 hours, within 3 hours of injury 1. Do not await viscoelastic assessment results before administration 1.

Calcium Supplementation

Monitor and maintain ionized calcium levels within normal range; administer calcium chloride to correct hypocalcemia 1

Definitive Bleeding Control

Surgical Intervention

• Consider damage-control surgery early in patients with hemorrhagic shock, ongoing bleeding, or coagulopathy 1
• Surgery may need to be interrupted and limited to damage control until bleeding is controlled 1

Imaging and Interventional Procedures

• Obtain rapid imaging (ultrasound, CT) when patient is sufficiently stable 1
• For pelvic fractures with hemorrhagic shock, perform immediate pelvic ring closure and stabilization 1
• Consider angioembolization or temporary extra-peritoneal packing if bleeding persists 1

Post-Resuscitation Care

Critical Care Monitoring

Admit to critical care for continuous monitoring of coagulation parameters, hemoglobin, blood gases, and wound drains 1, 2

Thromboprophylaxis

Commence standard venous thromboprophylaxis as soon as bleeding is controlled, as patients rapidly develop a prothrombotic state 1, 2

Common Pitfalls

• Avoid using derived fibrinogen levels—they are misleading; use Clauss fibrinogen only 1
• Do not delay tranexamic acid administration for laboratory confirmation 1
• Prevent dilutional coagulopathy by early FFP infusion rather than relying on crystalloid or colloid resuscitation 1
• Recognize that some patients compensate well despite significant blood loss; clinical assessment is paramount 1