What is the management of bleeding?

Management of Bleeding Per Rectum (PR)

For acute bleeding PR, immediately assess hemodynamic stability and establish IV access with fluid resuscitation targeting systolic blood pressure of 80-100 mmHg until bleeding is controlled, then proceed urgently to identify and control the bleeding source. 1

Immediate Assessment and Stabilization

• Minimize time between presentation and intervention - every minute counts in preventing mortality from hemorrhagic shock 1
• Establish large-bore IV access immediately and begin crystalloid resuscitation with lactated Ringer's solution in 250 mL aliquots 1, 2
• Target systolic blood pressure of 80-100 mmHg until definitive bleeding control is achieved (permissive hypotension strategy) [1, @16@]
• Monitor serum lactate and base deficit to estimate and track the severity of bleeding and shock - these are more reliable than single hematocrit measurements 1
• Do not rely on isolated hematocrit values as they are unreliable markers for acute bleeding severity 1

Hemodynamically Unstable Patients (Class III-IV Shock)

• Patients with hemorrhagic shock and identified bleeding source require immediate bleeding control procedures unless initial resuscitation rapidly stabilizes them 1
• Proceed directly to urgent intervention without delay for extensive diagnostic workup 1, 3
• Consider blood product transfusion early if signs of severe hypovolemia persist despite crystalloid resuscitation 3, 2
• For massive lower GI bleeding, early surgical or endoscopic intervention is critical - definitive hemostasis cannot be achieved medically 4, 2

Hemodynamically Stable Patients

• Perform CT angiography of the abdomen and pelvis with IV contrast when hemodynamic status allows 1, 3
• Early colonoscopy or angiography should be considered based on bleeding characteristics and clinical presentation 1
• Continue monitoring lactate and base deficit trends even in stable patients 1

Pharmacologic Adjuncts

• Consider tranexamic acid at 10-15 mg/kg IV bolus followed by 1-5 mg/kg/hour infusion for ongoing hemorrhage 1
• Infuse tranexamic acid no faster than 1 mL/minute to avoid hypotension 5
• Contraindications to tranexamic acid include: active intravascular clotting, subarachnoid hemorrhage, and history of hypersensitivity 5
• Be aware that tranexamic acid carries thromboembolic risk and seizure risk, particularly with renal dysfunction - adjust dosing accordingly 5

Surgical Intervention Criteria

• Damage control surgery is indicated for patients with deep hemorrhagic shock, ongoing bleeding with coagulopathy, hypothermia, acidosis, or need for time-consuming procedures 1, 6
• Early surgical bleeding control using packing and direct hemostatic procedures takes priority over prolonged resuscitation attempts 1, 7
• Angiographic embolization should be considered for patients with ongoing instability despite initial interventions 1

Critical Pitfalls to Avoid

• Never delay definitive bleeding control for extensive diagnostic workup in unstable patients - "scoop and run" to the OR or angiography suite 1, 2
• Avoid hyperventilation and excessive positive end-expiratory pressure in severely hypovolemic patients as this worsens hemodynamics 1
• Do not aggressively fluid resuscitate to normal blood pressure before bleeding control - this disrupts clot formation and worsens outcomes 1, 2
• Avoid administering tranexamic acid intrathecally - it is for IV use only and neuraxial administration causes seizures and cardiac arrhythmias 5
• Do not use tranexamic acid in patients on prothrombotic medications (Factor IX concentrates, hormonal contraceptives) due to compounded thrombosis risk 5

Monitoring During Resuscitation

• Serial lactate measurements every 30-60 minutes to assess adequacy of resuscitation 1
• Base deficit trending provides similar prognostic information 1
• Avoid relying on blood pressure alone - patients may maintain pressure until sudden decompensation 2, 7