What is the management for hemorrhage?

Management of Hemorrhage

Immediate control of bleeding through direct pressure, tourniquets, or surgical/radiological intervention is the first priority, followed by aggressive resuscitation with warmed blood products, active warming of the patient, and early administration of tranexamic acid within 3 hours of bleeding onset. 1

Immediate Actions

Control bleeding and secure access:

• Apply direct pressure, tourniquets, or haemostatic dressings to obvious bleeding points 1
• Establish large-bore IV access (ideally 8-Fr central access in adults) or consider intra-osseous access if peripheral access fails 1
• Administer high-flow oxygen 1

Initial assessment and monitoring:

• If the patient is conscious, talking, and has a palpable peripheral pulse, blood pressure is adequate—avoid aggressive normalization initially 1
• Obtain baseline labs: FBC, PT, aPTT, Clauss fibrinogen (not derived fibrinogen, which is misleading), and cross-match 1
• Use near-patient testing (TEG or ROTEM) if available 1

Resuscitation Strategy

Blood product administration:

• Resuscitate with warmed blood and blood components, not crystalloids alone 1
• Use blood group O initially (fastest), then group-specific, then cross-matched blood 1
• In major trauma, give fresh frozen plasma early in a 1:1 ratio with red blood cells until coagulation results are available 2
• Actively warm the patient and all transfused fluids to 37°C—this is mandatory 3

Coagulopathy management:

• Maintain fibrinogen levels >2 g/L in postpartum hemorrhage and >1.5 g/L in other hemorrhage 2
• Keep platelet count >75 × 10⁹/L (levels <50 × 10⁹/L are strongly associated with microvascular bleeding) 3
• Anticipate and prevent dilutional coagulopathy through early plasma infusion 1, 3

Tranexamic Acid Administration

Dosing and timing (critical for mortality benefit):

• Administer 1 g IV over 10 minutes, followed by 1 g over 8 hours 1, 4
• Must be given within 3 hours of bleeding onset—the effect is greatest when given early (RR 0.69 for mortality when given within 3 hours) 5
• No benefit when given >3 hours after bleeding onset 5
• Indicated in major trauma and postpartum hemorrhage, but NOT in gastrointestinal bleeding 2

Important caveats:

• Contraindicated in subarachnoid hemorrhage due to risk of cerebral edema and infarction 1, 6
• Use repeat doses cautiously in renal impairment (drug is renally excreted) 1
• Single bolus administration is likely preferable to bolus plus infusion regimen based on recent comparative data 7

Definitive Control

Surgical or radiological intervention:

• Consider surgery early; may need "damage control" approach—interrupt surgery to correct physiology before completing definitive repair 1
• Radiologically-guided arterial embolization is highly effective and may eliminate need for surgery, particularly in obstetric hemorrhage 1
• Alert theatre team about cell salvage autotransfusion needs 1

Ongoing Management

Physiological optimization:

• Once bleeding is controlled, aggressively normalize blood pressure, acid-base status, and temperature—but avoid vasopressors during active bleeding 1
• Restore organ perfusion without targeting normal blood pressure during active hemorrhage 1

Post-resuscitation care:

• Admit to critical care for monitoring of coagulation, hemoglobin, blood gases, and wound drains 1, 3
• Start venous thromboprophylaxis as soon as bleeding is controlled—patients rapidly develop a prothrombotic state 1, 3
• Consider temporary inferior vena cava filtration if needed 1

Common Pitfalls

• Delaying tranexamic acid administration: The mortality benefit disappears after 3 hours 5
• Using derived fibrinogen levels: These are misleading; only use Clauss fibrinogen 1
• Inadequate warming: Hypothermia exacerbates coagulopathy—warm the patient AND all fluids 3
• Over-resuscitation with crystalloids: This worsens dilutional coagulopathy; use blood products 3
• Giving tranexamic acid in subarachnoid hemorrhage: This is contraindicated 1, 6