14.2 - Massive Haemorrhage Flashcards
A 45-year-old man has a major haemorrhage following significant trauma and is admitted to your emergency department. He does not have a head injury.
a) Give one definition of major haemorrhage. (1 mark)
> > Loss of more than one blood volume within 24 hours (70 ml/kg or 5 l in a 70 kg adult).
> > 50% of total blood volume loss in less than three hours.
> > Bleeding in excess of 150 ml/min.
> > Bleeding that results in systolic blood pressure less than 90 mm Hg or heart rate greater than 110 bpm.
b) What are the principles of management of major haemorrhage in this patient? (11 marks)
This is a medical emergency. I would call for help and follow an ABCDE trauma team management approach to this patient, assessing and treating him simultaneously as issues are revealed
Institute the major haemorrhage protocol:
» Immediate release of blood components (packed red cells and fresh frozen plasma) for initial resuscitation without prior approval by
haematologist.
> > Communication to key personnel: on-call anaesthetists, surgeons, portering staff, blood bank staff.
> > Nominated individual to liaise with the laboratory.
Immediate patient management:
» Recognition of major haemorrhage: concealed or revealed, may have
multiple sources, start to control.
» A and B:
• 100% oxygen, definitive airway if indicated, cervical-spine control.
» C:
• Early haemorrhage control: pressure, tourniquets, immobilisation and
splinting until definitive intervention.
• Large-bore intravenous access (intraosseous if intravenous not
feasible).
• Take blood for cross-match, coagulation, full blood count, urea and
electrolytes, arterial blood gas. Repeat checks during resuscitation to
guide ongoing management. Use point-of-care testing if available.
• Use pressure infusers, blood warmers, cell salvage if applicable.
• Do not give clear fluids unless profoundly hypotensive and no blood
products imminently available.
• Allow permissive hypotension whilst the patient is actively haemorrhaging, avoid vasopressors.
• Follow protocol regarding patient identification prior to giving blood products.
• O negative should be immediately available in clinical area and can be used if there is a delay in blood issue from the blood bank. O positive may be used as patient is an adult male.
• Group specific blood should be ready in 15–20 minutes.
• Fresh frozen plasma should be given 1:1 with packed red cells to replace volume loss.
• Consider cryoprecipitate two pools and platelets one dose until bleeding is controlled and blood test results are available.
• Consider tranexamic acid 1 g.
• Establish whether the patient is taking drugs that interfere with coagulation. Discuss with haematologist and treat as indicated.
• Monitor resuscitation with point-of-care and laboratory tests:
– Fresh frozen plasma if INR greater than 1.5.
– Cryoprecipitate if fibrinogen less than 1.5 g/l.
– Platelets if platelet count less than 75 × 109/l.
• Catheterise to help guide ongoing fluid management.
> > D:
• The question states that there is no head injury. Monitor neurological status as another indicator of cardiovascular stability. Give paracetamol and cautious opioid-based pain relief as required.
> > E:
• Full exposure to check for all sources of bleeding.
• Initiate patient warming.
c) What complications might follow a massive blood transfusion? (8 marks)
> > Haemolytic reaction:
• Immediate: ABO incompatibility due to error. Delayed: Rhesus, Kidd, other minor blood groupings.
> > Non-haemolytic febrile reactions: reaction to donor leucocyte antigens.
> > Allergic reaction: recipient immunoglobulin E versus donor proteins.
> > Transfusion-related acute lung injury (TRALI): donor leucocyte antibodies reacting with human leucocyte antigens (HLA) and human neutrophil antigens (HNA) in the recipient.
> > Reaction due to bacterial contamination.
> > Transfusion-associated circulatory overload (TACO).
> > Hyperkalaemia: potassium content in stored blood rises with time due to loss of activity of red blood cell Na/K ATPase pump.
> > Citrate toxicity: large amounts of citrate in fresh frozen plasma and platelets, binds calcium resulting in hypocalcaemia, impacts on cardiac conduction and coagulation.
> > Acid base disturbance: citric acid from anticoagulant and lactic acid from stored cells. Metabolism of both usually rapid so may result in alkalosis.
> > Hypothermia.
> > Air embolism.
> > Thrombophlebitis.
> > Coagulation abnormalities if other blood components not given appropriately.
Late:
» Infection:
• Viral: Hepatitis A, B or C, HIV, CMV.
• Bacterial.
• Parasitic: malaria, toxoplasma.
• Prion: vCJD (risk reduced since universal leucodepletion of donated blood, exclusion of donors who have received blood transfusions in UK, sourcing of plasma for fractionation from abroad).
> > Immune sensitisation, e.g. to rhesus.
