Management of Lemon-Sized Clots
A patient passing lemon-sized clots represents massive hemorrhage requiring immediate activation of your institution's major hemorrhage protocol with simultaneous control of bleeding, large-bore IV access, aggressive blood product resuscitation, and urgent surgical or interventional consultation. 1
Immediate Actions (First 5-10 Minutes)
Activate the major hemorrhage protocol immediately - this mobilizes clinical, laboratory, and logistic resources including blood bank, surgical teams, and dedicated personnel 1
Control obvious bleeding points using direct pressure, tourniquets if applicable, or hemostatic dressings 1
Secure large-bore IV access - ideally 8-Fr central venous access in adults; if this fails, consider intra-osseous or surgical venous access 1
Administer high-flow oxygen to all patients 1
Assess hemodynamic status rapidly - if the patient is conscious, talking, and has a palpable peripheral pulse, blood pressure is adequate for now; avoid targeting normal BP initially as this may worsen bleeding 1
Critical Laboratory Assessment
Draw baseline labs immediately: complete blood count, PT, aPTT, Clauss fibrinogen (not derived), and cross-match 1
Utilize near-patient testing if available (TEG or ROTEM) to guide real-time coagulation management 1
Key coagulopathy thresholds to recognize 1:
- Fibrinogen <1 g/L indicates established hemostatic failure
- PT/aPTT >1.5 times normal predicts microvascular bleeding
- Target platelet count ≥75 × 10⁹/L in massive hemorrhage 1
Resuscitation Strategy
Fluid resuscitation means warmed blood and blood components - NOT crystalloid or colloid 1
Blood product availability hierarchy 1:
- O-negative blood (fastest, use only if immediate need)
- Group-specific blood (next fastest, no antibody screen needed)
- Cross-matched blood (when time permits)
Prevent dilutional coagulopathy with early FFP infusion at 15 mL/kg if massive hemorrhage is anticipated 1
For established coagulopathy, use fibrinogen concentrate or cryoprecipitate for rapid fibrinogen replacement (>15 mL/kg FFP will be needed) 1
Consider 1:1:1 red cell:FFP:platelet regimens for the most severely bleeding patients, as used in military trauma 1
Actively warm the patient and all transfused fluids to prevent hypothermia-induced coagulopathy 1
Anticoagulation Considerations
If the patient is on oral anticoagulants 1:
Stop all anticoagulants and antiplatelet agents immediately 1
For warfarin: administer 5-10 mg IV vitamin K plus prothrombin complex concentrate (PCC) based on INR 1
For DOACs: consider specific reversal agents (idarucizumab for dabigatran; andexanet alfa for apixaban/rivaroxaban) 1
Provide supportive care, volume resuscitation, and local therapy/manual compression 1
Definitive Management
Imaging and source control - rapid access to ultrasound, CT, or interventional radiology; consider FAST scanning if unstable 1
Early surgical consultation is mandatory - "damage control" surgery may be needed to control bleeding before full physiological correction 1
Once bleeding is controlled, aggressively normalize blood pressure, acid-base status, and temperature (but avoid vasopressors during active bleeding) 1
Post-Resuscitation Care
Admit to critical care for monitoring of coagulation, hemoglobin, blood gases, and wound drains to detect rebleeding 1
Start venous thromboprophylaxis as soon as bleeding is controlled - patients rapidly develop a prothrombotic state after massive hemorrhage 1
Common Pitfalls
Do not delay blood products waiting for crystalloid resuscitation - this worsens dilutional coagulopathy 1
Do not target normal blood pressure during active bleeding - permissive hypotension with adequate organ perfusion is appropriate until bleeding is controlled 1
Do not use derived fibrinogen levels - only Clauss fibrinogen is reliable in this setting 1
Do not forget to warm - hypothermia significantly worsens coagulopathy 1