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Acute > Acute haemorrhage > Flashcards

Acute haemorrhage Flashcards

1
Q

Why might young patients not be tachycardic despite a significant bleed?

A

Preserved vascular tone meaning they compensate for the bleed for longer by maintaing CO with vasoconstriction

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2
Q

Signs of abdominal bleeding on inspection?

A

Cullen’s/ Turner’s sign

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3
Q

What causes Cullen’s sign?

A

Cullen’s is hamorrhagic discolouration around to umbillicus due to intraperitoneal bleeding

  • Acute pancreatitis
  • Rupture ectopic pregnancy
  • Blunt force trauma to abdomen
  • Ovarian cyst haemorrhage
  • Ischaemic + gangrenous bowel
  • Ruptured aorta
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4
Q

What causes Turner’s sign?

A

Turner’s is bruising of the flank due to retroperitoneal haemorrhage

  • Severe necrotising pancreatitis
  • Ruptured AAA
  • Ruptured ectopic
  • Ruptured spleen
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5
Q

What could promote bleeding?

A

Anticoagulants

High BP

Liver failure

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6
Q

American college of surgeons acute haemorrhage classification

A

Stage 1: <750mL

Stage 2: 750-1500mL

Stage 3: 1500-2000mL

Stage 4: >2000mL

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7
Q

What is major haemorrhage?

A

50% blood loss within 3hrs or at a rate >150mL/ min - think equals ~2.5L in a 70kg male

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8
Q

What can make bleeding worse?

A

HAC​

  1. Hypothermia
  2. Acidosis
  3. Coagulopathy

Known as the lethal triad

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9
Q

Haemostatic resuscitation following major haemorrhage

A

Used red cell concentrates

Avoid using crystalloid because it dilutes clotting factors and can make bleeding worse

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10
Q

What is permissive hypotension?

A

Following major haemorrhage aim for a systolic BP of 80-90

This prevents high pressures breaking down clots

Fentanyl used to lower BP: symaptholysis and analgesia

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11
Q

Managing the haemorrhaging patient

A

Oxygen: they have a low Hb so the Hb they do have needs to be saturated with oxygen to prevent hypoperfusion

Establish IV access: 2 wide bore cannulas

Bloods: FBC (Hb and platelets), renal profile, U&E (hypocalcaemia can worsen bleeds), liver profile, clotting profile, group and save

CT angio: where are they bleeding from

Warmed IV fluid/ blood products to prevent hypothermia (part of the lethal triad)

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12
Q

How to control a bleed

A
  • Direct pressure e.g. splints/ pelvic binders
  • Red cell concentrate
  • TXA: some trials show it is of benefit, others don’t
  • Permissive hypotension: aim for a MAP of 65 (sBP+dBP+dBP/3)

*If MAP >65 consider using fentanyl to lower it

  • Correct clotting deficits
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13
Q

What does a star sign in CT angiography indicate?

A

Subarachnoid haemorrhage

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14
Q

What is cryoprecipitate?

A

Contaings fibrinogen, vWF, factor VIII, factor XIII

Given to patients with fibrinogen deficiency and those with haemophilia A (factor VIII deficiency)

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15
Q

What is given to patients with major haemorrhage on warfarin?

A

Prothrombin complex concentrate

Replaces vitamin K dependent factors 2, 7, 9 and 10 - always give with vitamin K

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16
Q

What is given to patients with vWF deficiency?

A

vWF promotes platelet aggregation and adhesion

If deficient, in cases of haemorrhage patients are given desmpressing or vWF concentrate

17
Q

Patient is thrombocytopenic (<30x10*9) - what do we do?

A

Give platelets…

Aim: 100x10*9

18
Q

Idaracizumab?

A

Used to reverse dabigatran

Monoclonal antibody that binds to dabigatran and its metabolites and reverses its effects

19
Q

1 unit of packed red cells will increase the Hb by how much?

A

10g/L (1g/dL)

20
Q

Target Hb following blood transfusion

A

After giving packed red cells aim for:

- 70-90g/L (7-9g/dL) Hb

- 80-100g/L (8-10g/dL) Hb in those with acute coronary syndrome

21
Q

Threshold value for giving packed red cells

A

70g/L Hb

22
Q

Target platelet count in major haemorrhage

A

100x10*9/ L

23
Q

What is the recommended dose of fresh frozen plasma?

A

12-15ml/kg - on average this is 4 units of FFP

This equates to 3-6 units of FFP depending on the patient’s weight

*Volume of FFP in a unit is variable - on average 275ml/ unit

24
Q

Clinical indications for fresh frozen plasma use

A
  1. Major haemorrhhage: give ratio of FFP: packed red cells 1:1 or 1:2
  2. PT/ INR >1.5 with bleeding: aim for PT and APTT ratio of <1.5
  3. Liver disease
  4. Thrombocytic thrombocytopenic purpura
  5. Replacement of single clotting factor
25
Q

When would we give cryoprecipitate?

A

In major haemorrhage if fibrinogen is <1.5g/L

26
Q

Avoiding the lethal triad in major haemorrhage

A

Hypothermia:

  • Remove wet clothing, ensure ambient temperature appropriate, continually monitor temp (rectal probe), use warming blankets, tranfuse warmed blood products

Acidosis:

  • Inadequate tissue perfusion = lactic acidosis which can impair clotting
  • Restore tissue perfusion ASAP with blood products (not crystalloids as these dilute existing blood)
  • Maximise oxygenation and minimise hypoventilation to avoid respiratory acidosis

Coagulopathy:

  • Avoid large volumes of crystalloid or unbalanced blood products because these can cause dilutional coagulopathy
  • Liaise with haematology from beginning
  • Manage major haemorrhage patient as though they are coagulopathic
27
Q

What is the ideal ratio of blood products in major haemorrhage?

A

2:1:1

Packed RBCs: FFP: platelets

*This does vary depending on trust*

28
Q

Which electrolyte derrangement is associated with increased bleeding risk?

A

Hypocalcaemia

29
Q

What is upper GI bleeding?

A

Bleeding from the GI tract above the ligament of Treitz

30
Q

How might a GI bleed be recognised?

A

70% have melaena

50% have haematemesis

PAtients with hx of liver disease, recent profuse vomiting (Mallory Weiss), peptic ulcer disease, alcohol use, NSAIDs

*Important to do a PR early as melaena may be present*

31
Q

What scoring systems can be used to identify high risk upper GI bleeds?

A

Glasgow-Blatchford - pre endoscopy

  • To identify those who can be discharged and those who will need intervention
  • Score of 0: consider discharge with outpatient endoscopy

Rockall - post endoscopy

  • To identify patients at risk of adverse outcome following acute upper GI bleeding
  • Score <3 = good prognosis
  • Score >8 = high risk of mortality
32
Q

Investigations for upper GI bleed

A

VBG: Hb level

U&E: urea raised as blood digested in stomach

FBC

Coagulation screen

LFTs

Cross match

33
Q

Management of upper GI bleeds

A

1st: Use Glasgow-Blatchford score to assess risk

Offer blood transfusion if Hb <8g/dL

a) Non-variceal bleed

  • PPI: reduces bleeding by increasing pH of gastric environment =which promotes clot stability
  • Urgent endoscopy: use adrenaline + clips/ thermal coagulation/ firbin or thrombin

b) Variceal bleed

  • Terlipressin: causes arterial constriction
  • Band ligation

*If endoscopy treatment fails to control the bleeding, consider TIPS procedure*

34
Q

What should be given to every patient in A&E with suspected variceal haemorrhage?

A

Terlipressin + broad spectrum antibiotics

35
Q

Gold standard for diagnosing and treating upper GI haemorrhage?

A

Endoscopy - controls bleeding in 90% patients with bleeding peptic ulcers

36
Q

What is used to control upper GI bleeding if medical therapy not working and endoscopy not immediately available?

A

Balloon tamponade - the idea is to buy time until endoscopy available

37
Q

What is transfusion associated circulatory overload?

A

Transfusion reaction that can occur due to rapid transfusion of a large volume of blood

Causes hypervolaemia

Can worsen oedema, cause tachycardia, increase BP, worsen pulmonary oedema

Management: stop transufsion, oxygen, diuretics

*Important to consider giving blood based on body weight and consider giving prophylactic diuretic*

38
Q

Which MAB can reverse dabigatran?

A

Idarucizumab

39
Q

Patient is on warfarin and is haemorrhaging - what do we do?

A

Stop warfarin, give phytomenadione (vitamin K1) and prothrombin complex

>> If prothrombin complex not available, five FFP - not as effective but better than nothing <<

Acute (22 decks)

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