What is the management protocol for a patient with a massive haemorrhage (severe bleeding)?

Massive Haemorrhage Protocol Management

Immediate Protocol Activation and First Actions

Activate the massive transfusion protocol immediately when massive haemorrhage is declared—do not wait for laboratory confirmation or formal thresholds, as the nature of the injury typically alerts you to probable massive haemorrhage before formal criteria are satisfied. 1

Critical First Steps (in order of priority):

• Control obvious bleeding immediately using direct pressure, tourniquets for extremity haemorrhage, or haemostatic dressings—this is the paramount priority 2, 1, 3
• Secure large-bore IV access with two large-bore peripheral cannulae; consider 8-Fr central access in adults or intraosseous access if peripheral fails 1, 4
• Administer high FiO₂ to ensure adequate oxygenation during haemorrhagic shock 1, 3
• Obtain baseline laboratory samples immediately: FBC, PT, aPTT, Clauss fibrinogen, blood bank sample, biochemical profile, and blood gases 1, 3

Blood Product Resuscitation Strategy

For severely traumatized patients with massive haemorrhage, use a 1:1:1 ratio of red blood cells:fresh frozen plasma:platelets, as this approach has demonstrated improved survival compared to historical practices. 1, 3

Blood Product Administration Protocol:

• Start with O-negative blood only if blood is needed immediately, limiting to 2 units maximum 1
• Transition rapidly to group-specific blood without antibody screening, as patients have minimal circulating antibodies during acute haemorrhage 2, 1
• Group-specific blood can be issued in approximately 10 minutes 1
• Administer early FFP at 10-15 ml/kg to prevent dilutional coagulopathy if a senior clinician anticipates massive haemorrhage 2, 1, 3
• Use warmed blood and blood components via a blood component administration set incorporating a 170-200 μm filter 1
• Administer platelets via a clean 170-200 μm giving set (not one previously used for red cells, as platelets may stick to residual red cells and reduce the effective transfused dose) 1

Coagulopathy Management Targets

Maintain fibrinogen >1 g/L, as levels below this threshold represent established haemostatic failure and predict microvascular bleeding. 2, 1, 3

Specific Coagulation Targets:

• Keep PT and aPTT <1.5 times normal, as values exceeding this indicate established coagulopathy 2, 1
• Target platelet count ≥75 × 10⁹/L throughout resuscitation 2, 1, 3
• For established coagulopathy (fibrinogen <1 g/L), administer more than 15 ml/kg of FFP 2, 3
• Use fibrinogen concentrate at 30-60 mg/kg or cryoprecipitate for rapid fibrinogen replacement, as fibrinogen concentrate requires no thawing 2, 1

Laboratory Monitoring Algorithm

• Repeat coagulation studies every 4 hours or after 1/3 blood volume replacement, as coagulopathy can develop rapidly 1
• Use near-patient testing (TEG or ROTEM) if available for rapid coagulation assessment 4
• Monitor blood lactate and base deficit as sensitive indicators of hypoperfusion and shock severity 4

Definitive Haemorrhage Control

• Pursue early surgical or obstetric intervention to arrest bleeding at the source 1, 3
• Consider damage control surgery to control bleeding before complete physiologic normalization 1, 3, 4
• Use rapid access to imaging (ultrasound, CT) or focused assessment with sonography for trauma scanning if patient sufficiently stable 4
• Encourage cell salvage autotransfusion in all cases to reduce need for donor blood 1, 3

Active Warming and Physiologic Optimization

• Actively warm the patient and all transfused fluids using adequate warming devices available in all emergency rooms and theatre suites 1, 4
• Once bleeding is controlled, aggressively normalize blood pressure, acid-base status, and temperature 1, 3, 4
• Monitor and correct electrolyte abnormalities, particularly hypocalcemia from citrate toxicity, to prevent cardiac dysfunction 3, 4

Post-Resuscitation Management

• Admit to critical care for ongoing monitoring of coagulation, haemoglobin, blood gases, and wound drains 1, 3
• Initiate standard venous thromboprophylaxis as soon as haemostasis is secured, as patients rapidly develop a prothrombotic state following massive haemorrhage 2, 1, 3, 4

Critical Pitfalls to Avoid

• Do not delay protocol activation—delaying activation increases mortality; activate early when massive haemorrhage is anticipated 3, 4
• Do not wait for laboratory results before administering blood products in obvious massive haemorrhage, as this increases mortality 3, 4
• Do not administer excessive crystalloid, as this causes dilutional coagulopathy and worsens outcomes; transition to blood products early 4
• Do not overdepend on O RhD negative red cells, as this may adversely impact local and national blood stock management 1
• Do not use haemoglobin level as the sole trigger for transfusion, as this fails to account for the dynamic nature of haemorrhagic shock 4
• Do not attempt to achieve normal blood pressure initially—restore organ perfusion but avoid aggressive normalization until bleeding is controlled 4

Special Considerations

Warfarin Reversal (if applicable):

• Use prothrombin complex concentrate (PCC) at 25 u/kg for INR 2-3.9,35 u/kg for INR 4-5.9, or 50 u/kg for INR >6, plus intravenous vitamin K 5-10 mg 1

Recombinant Factor VIIa:

• For congenital haemophilia A or B with inhibitors: 90 mcg/kg every 2 hours until haemostasis is achieved 5
• For acquired haemophilia: 70-90 mcg/kg every 2-3 hours until haemostasis is achieved 5
• Monitor and minimize the duration of any post-haemostatic dosing 5

Obstetric Haemorrhage:

• Anticipate consumptive coagulopathy and hyperfibrinolysis, which are particularly associated with obstetric haemorrhage 1
• Greater use of cryoprecipitate or fibrinogen concentrate may be beneficial 6