Acute haemorrhage Flashcards
Why might young patients not be tachycardic despite a significant bleed?
Preserved vascular tone meaning they compensate for the bleed for longer by maintaing CO with vasoconstriction
Signs of abdominal bleeding on inspection?
Cullen’s/ Turner’s sign
What causes Cullen’s sign?
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
What causes Turner’s sign?
Turner’s is bruising of the flank due to retroperitoneal haemorrhage
- Severe necrotising pancreatitis
- Ruptured AAA
- Ruptured ectopic
- Ruptured spleen
What could promote bleeding?
Anticoagulants
High BP
Liver failure
American college of surgeons acute haemorrhage classification
Stage 1: <750mL
Stage 2: 750-1500mL
Stage 3: 1500-2000mL
Stage 4: >2000mL
What is major haemorrhage?
50% blood loss within 3hrs or at a rate >150mL/ min - think equals ~2.5L in a 70kg male
What can make bleeding worse?
HAC
- Hypothermia
- Acidosis
- Coagulopathy
Known as the lethal triad
Haemostatic resuscitation following major haemorrhage
Used red cell concentrates
Avoid using crystalloid because it dilutes clotting factors and can make bleeding worse
What is permissive hypotension?
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
Managing the haemorrhaging patient
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)
How to control a bleed
- 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
What does a star sign in CT angiography indicate?
Subarachnoid haemorrhage
What is cryoprecipitate?
Contaings fibrinogen, vWF, factor VIII, factor XIII
Given to patients with fibrinogen deficiency and those with haemophilia A (factor VIII deficiency)
What is given to patients with major haemorrhage on warfarin?
Prothrombin complex concentrate
Replaces vitamin K dependent factors 2, 7, 9 and 10 - always give with vitamin K
What is given to patients with vWF deficiency?
vWF promotes platelet aggregation and adhesion
If deficient, in cases of haemorrhage patients are given desmpressing or vWF concentrate
Patient is thrombocytopenic (<30x10*9) - what do we do?
Give platelets…
Aim: 100x10*9
Idaracizumab?
Used to reverse dabigatran
Monoclonal antibody that binds to dabigatran and its metabolites and reverses its effects
1 unit of packed red cells will increase the Hb by how much?
10g/L (1g/dL)
Target Hb following blood transfusion
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
Threshold value for giving packed red cells
70g/L Hb
Target platelet count in major haemorrhage
100x10*9/ L
What is the recommended dose of fresh frozen plasma?
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
Clinical indications for fresh frozen plasma use
- Major haemorrhhage: give ratio of FFP: packed red cells 1:1 or 1:2
- PT/ INR >1.5 with bleeding: aim for PT and APTT ratio of <1.5
- Liver disease
- Thrombocytic thrombocytopenic purpura
- Replacement of single clotting factor
When would we give cryoprecipitate?
In major haemorrhage if fibrinogen is <1.5g/L
Avoiding the lethal triad in major haemorrhage
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
What is the ideal ratio of blood products in major haemorrhage?
2:1:1
Packed RBCs: FFP: platelets
*This does vary depending on trust*
Which electrolyte derrangement is associated with increased bleeding risk?
Hypocalcaemia
What is upper GI bleeding?
Bleeding from the GI tract above the ligament of Treitz
How might a GI bleed be recognised?
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*
What scoring systems can be used to identify high risk upper GI bleeds?
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
Investigations for upper GI bleed
VBG: Hb level
U&E: urea raised as blood digested in stomach
FBC
Coagulation screen
LFTs
Cross match
Management of upper GI bleeds
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*
What should be given to every patient in A&E with suspected variceal haemorrhage?
Terlipressin + broad spectrum antibiotics
Gold standard for diagnosing and treating upper GI haemorrhage?
Endoscopy - controls bleeding in 90% patients with bleeding peptic ulcers
What is used to control upper GI bleeding if medical therapy not working and endoscopy not immediately available?
Balloon tamponade - the idea is to buy time until endoscopy available
What is transfusion associated circulatory overload?
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*
Which MAB can reverse dabigatran?
Idarucizumab
Patient is on warfarin and is haemorrhaging - what do we do?
Stop warfarin, give phytomenadione (vitamin K1) and prothrombin complex
>> If prothrombin complex not available, five FFP - not as effective but better than nothing <<
