What is the management of massive hemorrhage?

Management of Massive Hemorrhage

Immediately activate your massive transfusion protocol and begin resuscitation with blood products in a 1:1:1 ratio (RBC:FFP:platelets) while simultaneously controlling the source of bleeding—delays in either action directly increase mortality. 1, 2

Immediate Hemorrhage Control (First Priority)

• Apply direct pressure to all obvious bleeding points using your hands, hemostatic dressings, or tourniquets for extremity hemorrhage—this remains the single most effective initial intervention. 1, 2, 3, 4
• Secure large-bore IV access immediately (ideally 8-Fr central access in adults); if peripheral access fails, proceed directly to intra-osseous or surgical venous access without delay. 1, 2, 3
• Administer high-flow oxygen (high FiO2) to maximize oxygen delivery to hypoperfused tissues. 1, 2, 3

Blood Product Resuscitation Strategy

Begin transfusing blood products immediately in a 1:1:1 ratio (RBC:FFP:platelets) without waiting for laboratory results—this military-derived protocol prevents dilutional coagulopathy before it develops and has been associated with improved survival in observational studies. 1, 2, 5, 6

Initial Blood Product Administration:

• Start with O negative blood only if cross-matched blood is needed immediately; otherwise use group-specific blood (which can be issued without antibody screening in massive hemorrhage). 1
• Administer early FFP at 10-15 ml/kg to prevent dilutional coagulopathy—do not wait for coagulation studies to show abnormalities. 1, 2
• Warm all blood products and resuscitation fluids using active warming devices to prevent hypothermia-induced coagulopathy. 1, 2
• Minimize or avoid crystalloid administration entirely, as excessive crystalloid causes dilutional coagulopathy and worsens outcomes. 1

Platelet and Fibrinogen Targets:

• Maintain platelet count >75 × 10⁹/L throughout resuscitation—levels below 50 × 10⁹/L strongly predict microvascular bleeding. 1, 2, 3
• Target fibrinogen >1 g/L using fibrinogen concentrate or cryoprecipitate; fibrinogen <1 g/L represents established hemostatic failure. 1, 2
• For established coagulopathy (PT/aPTT >1.5× normal), administer >15 ml/kg FFP. 1, 2

Laboratory and Point-of-Care Assessment

• Obtain baseline labs (FBC, PT, aPTT, Clauss fibrinogen, cross-match) but do not delay transfusion waiting for results. 1, 2
• Use viscoelastic testing (TEG or ROTEM) for rapid coagulation assessment if available—these whole blood assays identify coagulopathy faster than conventional tests and enable goal-directed transfusion therapy. 1, 6, 7
• Monitor blood lactate and base deficit as sensitive indicators of shock severity and adequacy of resuscitation. 1

Definitive Hemorrhage Control

• Activate surgical consultation immediately—damage control surgery may be necessary, limited to controlling bleeding before complete physiologic normalization. 1, 2, 3
• Consider radiologically-guided arterial embolization, which is highly effective and may eliminate the need for surgery, particularly in pelvic or obstetric hemorrhage. 3
• Perform focused assessment with sonography for trauma (FAST) or rapid CT imaging only if the patient is sufficiently stable. 1
• Alert the operating room team about cell salvage autotransfusion needs. 1, 2

Physiologic Optimization During Active Bleeding

• Do not aggressively normalize blood pressure during active bleeding—restore organ perfusion but avoid vasopressors and aggressive normalization until bleeding is controlled. 1, 3
• Once bleeding is controlled, aggressively normalize blood pressure, acid-base status, and temperature. 1, 2, 3
• Monitor and correct hypocalcemia from citrate toxicity (from massive transfusion) to prevent cardiac dysfunction. 1, 2

Adjunctive Pharmacologic Therapy

• Administer tranexamic acid 1 g IV over 10 minutes, followed by 1 g over 8 hours—but only if given within 3 hours of bleeding onset for maximum mortality benefit. 3
• Avoid recombinant factor VIIa (rFVIIa) as routine therapy due to thromboembolic risks; reserve for refractory coagulopathy after standard measures have failed. 8

Post-Resuscitation Critical Care

• Admit to intensive care for continuous monitoring of coagulation parameters, hemoglobin, blood gases, and assessment for ongoing bleeding. 1, 2, 3
• Initiate venous thromboprophylaxis as soon as hemostasis is secured—patients rapidly develop a prothrombotic state following massive hemorrhage. 1, 2, 3

Critical Pitfalls to Avoid

• Never delay massive transfusion protocol activation—waiting for laboratory confirmation of massive hemorrhage increases mortality; activate based on clinical assessment alone. 1, 2
• Never resuscitate with crystalloids alone or delay blood product administration—this causes dilutional coagulopathy and directly worsens outcomes. 1
• Never use hemoglobin level as the sole transfusion trigger—this fails to account for the dynamic nature of hemorrhagic shock and ongoing coagulopathy. 1
• Never attempt to achieve normal blood pressure with vasopressors during active bleeding—this worsens hemorrhage before surgical control is achieved. 1, 3