What are the steps to control overt bleeding?

Control of Overt Bleeding

Immediately prioritize direct hemorrhage control through temporary hemostatic devices (pressure, tourniquets) followed by definitive surgical or interventional radiological control as soon as practically possible. 1

Initial Assessment and Immediate Actions

Rapid Clinical Evaluation

• Assess bleeding severity using hemodynamic status, visible blood loss, and physiologic parameters (skin color, heart rate, blood pressure, capillary refill, conscious level) 1
• Classify as major bleeding if any of the following apply: bleeding at a critical site, hemodynamic instability, or clinically overt bleeding with hemoglobin decrease ≥2 g/dL or requiring ≥2 units RBC transfusion 1
• Estimate blood loss using serum lactate and base deficit to monitor extent of bleeding and shock 1

Immediate Hemorrhage Control Measures

Apply direct mechanical control first:

• Use direct pressure at the bleeding site 1
• Apply tourniquets for extremity hemorrhage 1
• Proceed to surgical or interventional radiological control as soon as practically possible 1

For trauma patients with unidentified bleeding source:

• Perform early focused sonography (FAST) for detection of free fluid in suspected torso trauma 1
• Patients with significant free intraabdominal fluid and hemodynamic instability should undergo urgent surgery 1
• Hemodynamically stable patients with suspected internal bleeding should undergo CT imaging 1

For pelvic hemorrhage:

• Patients with pelvic ring disruption in hemorrhagic shock require immediate pelvic ring closure and stabilization 1
• If ongoing instability despite stabilization, proceed to early angiographic embolization or surgical bleeding control including packing 1

Resuscitation Strategy During Active Bleeding

Permissive Hypotension

Do not attempt to normalize blood pressure during active hemorrhage - maintain target systolic blood pressure of 80-100 mmHg until major bleeding is controlled (modify for head/spinal injuries) 1

Fluid Management

• Avoid crystalloid and colloid administration during uncontrolled hemorrhage unless profound hypotension exists with no imminent blood product availability 1
• Avoid vasopressors during active hemorrhage 1
• Once hemorrhage is controlled, aggressively normalize blood pressure, but vasopressors should still be avoided initially 1

Blood Product Administration

During active hemorrhage with trauma-induced coagulopathy:

• Administer RBC and FFP in 1:1 ratio for volume replacement while hemorrhage is being controlled 1
• Consider administration of cryoprecipitate (two pools) and platelets (one adult therapeutic dose) until test results available 1

Pediatric dosing (per kg body weight):

• RBC: 10 ml/kg (increases Hb by approximately 20 g/L) 1
• Cryoprecipitate: 5-10 ml/kg 1
• Platelets: 10-20 ml/kg 1
• FFP: 10-15 ml/kg 1

Transfusion Thresholds

• Use restrictive RBC transfusion thresholds (Hb trigger 70 g/L, target 70-90 g/L) for most patients 2, 3
• For patients with cardiovascular disease, use higher threshold (Hb trigger 80 g/L, target 100 g/L) 3

Pharmacologic Hemostatic Agents

Tranexamic Acid (TXA) - First-Line Antifibrinolytic

For trauma patients:

• Give 1 g immediately (or 10-15 mg/kg loading dose) 1
• Follow with infusion of 1-5 mg/kg/hour 1
• Avoid if >3 hours after injury unless ongoing evidence of hyperfibrinolysis on point-of-care testing 1

Pediatric trauma dosing:

• Loading dose: 15 mg/kg 1
• Infusion: 2 mg/kg/hour 1

Mechanism and efficacy:

• TXA prevents clot breakdown through reversible blockade of lysine binding sites on plasminogen 4
• Reduces postoperative blood losses by 29-54% in cardiac surgery 4
• Reduces mortality by 40% in upper gastrointestinal bleeding 4

Reversal Agents for Anticoagulated Patients

For patients on oral anticoagulants with major bleeding:

• Stop anticoagulant immediately 1, 2, 3
• Stop concomitant antiplatelet agents 1, 3

For warfarin (VKA):

• Give 5-10 mg IV vitamin K 1
• Administer prothrombin complex concentrate (PCC) for rapid reversal 1

For apixaban or rivaroxaban:

• Administer andexanet alfa for life-threatening hemorrhage: 400 mg IV bolus followed by 4 mg/min infusion for up to 120 minutes 2, 3

For dabigatran:

• Administer idarucizumab as specific reversal agent 1

Surgical Management

Damage Control Surgery Indications

Employ damage control surgery in severely injured patients with: 1

• Deep hemorrhagic shock with signs of ongoing bleeding
• Coagulopathy, hypothermia, acidosis
• Inaccessible major anatomic injury
• Need for time-consuming procedures
• Concomitant major injury outside the abdomen

Surgical Techniques

• Achieve early bleeding control using packing, direct surgical control, and local hemostatic procedures 1
• Aortic cross-clamping may be employed as adjunct in exsanguinating patients 1

Supportive Measures

Temperature Management

• Actively warm the patient and all transfused fluids to prevent hypothermia 1
• Children are at particular risk of hypothermia during rapid blood product administration 1

Monitoring

• Use viscoelastic testing (if available) to guide transfusion 1
• Monitor coagulation parameters, hemoglobin, and blood gases 1
• Single hematocrit measurements should not be used as isolated laboratory marker for bleeding 1

Post-Hemorrhage Care

• Admit to critical care area for monitoring after massive hemorrhage 1
• Commence venous thromboprophylaxis as soon as bleeding controlled, as patients rapidly develop prothrombotic state 1
• Consider temporary inferior vena cava filtration if needed 1

Common Pitfalls to Avoid

• Do not delay definitive hemorrhage control - temporary measures must transition quickly to surgical/interventional control 1
• Do not aggressively fluid resuscitate to normal blood pressure during active bleeding - this worsens hemorrhage 1
• Do not give TXA >3 hours post-trauma unless hyperfibrinolysis documented 1
• Do not rely on single hematocrit to assess bleeding severity 1
• Do not use vasopressors during active hemorrhage 1