What is the treatment for spontaneous bleeding?

Treatment of Spontaneous Bleeding

The treatment of spontaneous bleeding depends critically on the anatomic location and underlying cause, with immediate bleeding control procedures taking priority over diagnostic workup in hemodynamically unstable patients. 1

Initial Assessment and Stabilization

Immediate Triage Based on Bleeding Type

For patients presenting with hemorrhagic shock and an identified bleeding source, proceed directly to bleeding control procedures without delay unless initial resuscitation rapidly stabilizes the patient. 1

• Epistaxis (nosebleeds): Have the patient sit upright with head tilted slightly forward, pinch the soft lower third of the nose continuously for 10-15 minutes while breathing through the mouth 1
• Eye bleeding after trauma: Seek immediate medical attention for any eye bleeding, irregular pupil, high-velocity injury, or vision loss 1
• Intra-abdominal or torso bleeding: Perform focused abdominal sonography (FAST) immediately to detect free fluid in hemodynamically unstable patients 1
• Intracranial hemorrhage: Initiate aggressive blood pressure control targeting systolic BP of 140 mmHg and reverse any coagulopathy emergently 1, 2

Hemodynamic Management

Target a systolic blood pressure of 80-100 mmHg in trauma patients until major bleeding is controlled, but avoid permissive hypotension in intracerebral hemorrhage where aggressive BP control to 140 mmHg systolic is required. 1, 2

• Initiate crystalloid resuscitation first, with colloids added within prescribed limits for each solution 1
• Monitor serum lactate and base deficit to estimate and track the extent of bleeding and shock 1
• Avoid excessive fluid resuscitation that may worsen cerebral edema in brain hemorrhage 2

Reversal of Anticoagulation

Warfarin-Associated Bleeding

For patients on warfarin with INR ≥2.0, administer 4-factor prothrombin complex concentrate (PCC) immediately rather than fresh frozen plasma, as PCC achieves rapid INR correction and limits hematoma expansion. 1

• Give intravenous vitamin K directly after PCC administration to prevent later INR increase 1
• For INR 1.3-1.9, PCC administration may be reasonable to limit hematoma expansion 1
• Critical pitfall: Vitamin K alone (especially oral or subcutaneous) does not improve INR in liver disease and should not be used as monotherapy 1

Direct Oral Anticoagulants (DOACs)

For factor Xa inhibitor-associated bleeding (rivaroxaban, apixaban, edoxaban), administer andexanet alfa to reverse anticoagulation. 1

For dabigatran-associated bleeding, administer idarucizumab for immediate reversal. 1

• Do not wait for coagulation test results—treat based on medication history and timing of last dose 1

Hemostatic Therapy

Tranexamic Acid for Brain Hemorrhage

Administer tranexamic acid 1 gram IV over 10 minutes followed by 1 gram IV over 8 hours as soon as possible after identifying intracranial hemorrhage, ideally within 3 hours of injury. 3

• Do not wait for viscoelastic testing before administering TXA 3
• Greatest benefit occurs when given within the first hour of injury 3
• Adjust dosing in renal impairment (GFR <50 mL/min) 3
• Monitor for thromboembolic events, especially in elderly patients 3

Antifibrinolytic Agents for Trauma

For bleeding trauma patients, tranexamic acid 10-15 mg/kg followed by infusion of 1-5 mg/kg/hour may be considered. 1

• Alternative: ε-aminocaproic acid 100-150 mg/kg followed by 15 mg/kg/hour, though TXA is preferred 1, 3

Surgical and Interventional Management

Pelvic Hemorrhage

Patients with pelvic ring disruption in hemorrhagic shock require immediate pelvic ring closure and stabilization. 1

• If hemodynamic instability persists despite pelvic stabilization, proceed to early angiographic embolization or surgical packing 1

Intra-abdominal Bleeding

Patients with significant free intraabdominal fluid on FAST and hemodynamic instability require urgent surgery. 1

• Employ damage control surgery in severely injured patients with deep hemorrhagic shock, ongoing bleeding, coagulopathy, hypothermia, or acidosis 1
• Use packing, direct surgical control, and local hemostatic procedures as primary bleeding control methods 1

Intracranial Hemorrhage

Consider ICP monitoring for patients with GCS ≤8, clinical transtentorial herniation, or significant mass effect. 2

• Maintain cerebral perfusion pressure of 50-70 mmHg 2
• Ventricular drainage is reasonable for hydrocephalus, especially with decreased consciousness 2
• Never use corticosteroids for intracerebral hemorrhage—they are contraindicated 2

Specific Bleeding Disorders

Hemophilia A and von Willebrand Disease

For hemophilia A patients with factor VIII levels >5% experiencing spontaneous bleeding episodes (hemarthroses, intramuscular hematomas, mucosal bleeding), administer desmopressin acetate injection 30 minutes prior to procedures or for acute bleeding. 4

• Also effective for mild to moderate von Willebrand disease (Type I) with factor VIII >5% 4
• Not indicated for hemophilia A with factor VIII ≤5%, hemophilia B, or patients with factor VIII antibodies 4

Critical Pitfalls to Avoid

Do not rely on traditional coagulation tests (INR, aPTT, platelet count) to predict bleeding risk or guide prophylactic transfusion in cirrhosis—these tests do not correlate with spontaneous bleeding. 1

• Prophylactic FFP does not prevent spontaneous bleeding and risks transfusion-associated circulatory overload 1
• Platelet transfusions for spontaneous bleeding prevention in cirrhosis lack evidence—platelet count does not predict bleeding episodes 1
• Prophylactic cryoprecipitate for low fibrinogen (<150 mg/dL) does not reduce bleeding or mortality risk 1

Do not use single hematocrit measurements as isolated markers for bleeding—they are unreliable. 1, 2

When to Seek Emergency Care

Patients should seek immediate medical attention for: 1

• Epistaxis not stopping after 15 minutes of continuous pressure 1
• Lightheadedness from epistaxis 1
• Epistaxis while taking anticoagulants or antiplatelet medications 1
• Nasal bleeding from trauma with signs of brain injury, nasal deformity, or facial fracture 1