What is the management of massive bleeding?

Management of Massive Bleeding

Immediately control obvious bleeding with direct pressure, tourniquets, or hemostatic dressings while simultaneously activating your institution's massive transfusion protocol and securing large-bore IV access—delay in protocol activation increases mortality. 1, 2, 3

Immediate Resuscitation Actions

Hemorrhage Control and Airway Management

• Apply direct pressure, tourniquets, or hemostatic dressings to all visible bleeding sites as the paramount priority 4, 1
• Administer high FiO₂ to ensure adequate oxygenation during the resuscitation 4, 1
• Secure large-bore IV access immediately—8-Fr central access is ideal in adults; if this fails, proceed to intra-osseous or surgical venous access 4, 1

Critical Laboratory Assessment

• Obtain baseline bloods immediately: FBC, PT, aPTT, Clauss fibrinogen (not derived fibrinogen, which is misleading), and cross-match 4, 1
• Use near-patient testing with TEG or ROTEM if available for rapid coagulation assessment—these viscoelastic assays identify coagulopathy more effectively than conventional tests 4, 1, 5
• Monitor blood lactate and base deficit as sensitive indicators of hypoperfusion severity 1

Blood Product Resuscitation Strategy

Balanced Ratio Transfusion Protocol

• Administer blood products in a 1:1:1 ratio of RBC:FFP:platelets for severely injured patients with massive hemorrhage—this military-derived approach has demonstrated improved survival 1, 2, 3
• Begin early FFP administration at 10-15 ml/kg to prevent dilutional coagulopathy before it develops if a senior clinician anticipates massive hemorrhage 1, 2, 3
• Use warmed blood and blood components exclusively—blood group O is quickest, followed by group-specific, then cross-matched blood 4, 1
• In massive bleeding, group-specific blood can be issued without performing an antibody screen because patients will have minimal circulating antibodies 1

Coagulopathy Management Targets

• Fibrinogen <1 g/L or PT/aPTT >1.5 times normal represents established hemostatic failure and predicts microvascular bleeding 1, 2
• Established coagulopathy requires more than 15 ml/kg of FFP to correct 1, 2
• The most effective way to achieve rapid fibrinogen replacement is by giving fibrinogen concentrate or cryoprecipitate if fibrinogen concentrate is unavailable 1, 2, 3
• Maintain a minimum target platelet count of 75 × 10⁹/L throughout resuscitation 1, 2, 3

Physiologic Optimization

Temperature and Hemodynamic Management

• Actively warm the patient and all transfused fluids using adequate warming devices—hypothermia exacerbates coagulopathy 4, 1
• Restore organ perfusion, but do not attempt to achieve normal blood pressure initially—permissive hypotension is appropriate until bleeding is controlled 4, 1
• Once bleeding is controlled, aggressively normalize blood pressure, acid-base status, and temperature, but avoid vasopressors 4, 1
• Monitor and correct electrolyte abnormalities, particularly hypocalcemia from citrate toxicity, to prevent cardiac dysfunction 1, 2

Definitive Hemorrhage Control

Surgical and Radiological Intervention

• Consider surgery early—damage control surgery may be necessary, limited to controlling bleeding before complete physiologic normalization 4, 1
• Arrange rapid access to imaging (ultrasound, radiography, CT) or focused assessment with sonography for trauma scanning if the patient is sufficiently stable 4, 1
• Alert the theatre team about the need for cell salvage autotransfusion 4, 1
• Surgery may need to be interrupted and limited to "damage control" until abnormal physiology can be corrected 4

Post-Resuscitation Management

Critical Care Monitoring

• Admit to a critical care area for ongoing monitoring of coagulation, hemoglobin, blood gases, and wound drain assessment to identify overt or covert bleeding 4, 1
• Commence standard venous thromboprophylaxis as soon as possible after bleeding is controlled—patients rapidly develop a prothrombotic state following massive hemorrhage 4, 1
• Temporary inferior vena cava filtration may be necessary in select cases 4

Critical Pitfalls to Avoid

Common Errors That Increase Mortality

• Do not delay activation of the massive transfusion protocol—activate immediately when massive hemorrhage is declared, as delay increases mortality 1, 2, 3
• Do not wait for laboratory results before administering blood products in obvious massive hemorrhage—this increases mortality 1, 2
• Do not administer excessive crystalloid—this causes dilutional coagulopathy and worsens outcomes; transition to blood products early 1, 6, 5
• Do not use hemoglobin level as the sole trigger for transfusion—this fails to account for the dynamic nature of hemorrhagic shock 1
• Do not use derived fibrinogen levels—these are misleading and should not guide therapy 4

Team Organization Requirements

• Designate a team leader (usually the most senior physician) to declare massive hemorrhage and coordinate management 4, 3
• Assign specific roles: communications lead, dedicated personnel for blood product transport, and IV access specialist 4, 3
• Ensure constant communication between the laboratory and clinical area, ideally via radio 4