What is the management approach for massive blood loss?

Management of Massive Blood Loss

Immediately activate your hospital's major haemorrhage protocol, establish large-bore IV access (≥14G), and simultaneously pursue three priorities: restore circulating volume with warmed fluids, achieve surgical haemostasis, and correct coagulopathy with early fresh frozen plasma (FFP) administration. 1

Immediate Actions and Team Activation

• Designate a coordinator from permanent clinical staff to manage communication, documentation, and liaison between surgical, anaesthetic, haematology teams, blood bank, and laboratory services 1
• Activate the major haemorrhage protocol immediately when massive haemorrhage is declared—this mobilizes clinical, laboratory, and logistic responses simultaneously 1
• Apply direct pressure to any obvious bleeding source as the most effective initial medical intervention for haemorrhage control; use tourniquets or haemostatic dressings for extremity bleeding 1

Volume Resuscitation Strategy

• Insert two large-bore peripheral cannulae (14 gauge or larger) for rapid fluid administration 1
• Infuse warmed crystalloid or colloid rapidly to restore circulating volume; hypothermia dramatically increases mortality from organ failure and DIC 1
• Use blood warmers when infusion rate exceeds 50 ml/kg/h in adults to prevent hypothermia 1
• Monitor central venous pressure and aim to maintain normal blood pressure with urine output >30 ml/h 1
• Consider permissive hypotension in ongoing uncontrolled bleeding to limit further blood loss, though this must be balanced against organ perfusion 2

Blood Product Administration

Red Blood Cells

• In extreme emergency: Use un-crossmatched group O Rh-negative blood (Rh-positive acceptable for males or postmenopausal females), limited to 2 units maximum 1
• When blood group known: Use un-crossmatched ABO group-specific blood; laboratory completes cross-match after issue 1
• After 1 blood volume replacement (8-10 units): Further cross-matching not required 1
• Target haemoglobin: Maintain 7-9 g/dL generally, but 10 g/dL is reasonable in actively bleeding patients, elderly, or those at risk for myocardial infarction 3, 2

Fresh Frozen Plasma (FFP)

• Administer early FFP (15 ml/kg or 4 units for adults) when a senior clinician anticipates massive haemorrhage, before coagulopathy develops 1
• Target PT and APTT <1.5 times control mean; fibrinogen <1 g/L or PT/APTT >1.5 times normal indicates established haemostatic failure predictive of microvascular bleeding 1
• Allow 30 minutes for thawing time and coordinate early with blood centre as delivery may take up to 2 hours 1
• For massive transfusion: Use 4:4:1 ratio of red blood cells:FFP:pooled platelets in severely traumatized patients requiring massive transfusion 1, 2

Fibrinogen Replacement

• Aim for fibrinogen >1.0 g/L; fibrinogen <0.5 g/L is strongly associated with microvascular bleeding 1
• Use fibrinogen concentrate or cryoprecipitate for rapid fibrinogen replacement; fibrinogen deficiency develops early when plasma-poor red cells are used 1, 4
• Allow for delivery time plus 30 minutes thawing for cryoprecipitate 1

Platelets

• Maintain platelet count >75 × 10⁹/L in massive haemorrhage situations 1
• Anticipate platelet count <50 × 10⁹/L after 2 blood volume replacement 1

Laboratory Monitoring

• Obtain baseline samples immediately: FBC, PT, APTT, fibrinogen, blood bank sample, biochemical profile, blood gases 1
• Ensure correct sample identity—misidentification is the commonest transfusion risk 1
• Repeat coagulation studies every 4 hours or after 1/3 blood volume replacement; you may need to give components before results are available 1
• Repeat testing after blood component infusion to guide ongoing therapy 1

Surgical Haemostasis

• Pursue early surgical or obstetric intervention to arrest bleeding at the source 1
• Consider interventional radiology for haemorrhage control when appropriate 1
• Employ intraoperative blood salvage if available and appropriate; contraindicated if wound is heavily contaminated 1

Critical Pitfalls to Avoid

• Blood loss is frequently underestimated in clinical practice; haemoglobin and haematocrit do not fall for several hours after acute haemorrhage 1, 5
• Stable vital signs do not exclude significant blood loss—silent ischaemia may occur despite apparently stable haemodynamics 1, 5
• Hypothermia, acidosis, and shock create a lethal triad leading to DIC with high mortality 1
• Coagulopathy develops early: Hypofibrinogenaemia occurs first, followed by other coagulation factor deficits, then thrombocytopenia 4, 6
• Loss of >40% blood volume is immediately life-threatening; red cell transfusion typically required when 30-40% blood volume is lost 1, 5

Adjunctive Considerations

• Consider tranexamic acid for haemorrhage control in appropriate clinical contexts, though be aware of thromboembolic risks and seizure potential 7, 2
• Maintain normothermia, pH >7.2, and normocalcaemia as essential treatment principles 2
• Commence venous thromboprophylaxis as soon as haemostasis is secured, as patients develop a prothrombotic state following massive haemorrhage 1