Hemorrhage

Question 1

Massive transfusion or critical hemorrhage

Answer 1

> 1 blood volume/24 h, >1/2 volume/4h, >150ml/min.

Question 2

Sodium chloride 0.9%

Answer 2

pH 5.5, osmolarity 308 mOsm/l, formula per 1000 ml: water for injection 9 g Sodium chloride, sodium 154 mmol per 1000 ml, chloride 154 mmol per 1000 ml.

Question 3

Ringer lactate/Hartman’s solution/ compound sodium lactate Bp

Answer 3

pH 5.0-7.0, formula per 1000 ml: sodium chloride 6.0 g+potassium chloride 0,4 g+ calcium chloride dihydrate 0,27 g+sodium lactate 3,2 g+water for injection. Sodium 131 mmol/l, chloride 111 mmol/l, bicarbonate 29 mmol/l, potassium 5 mmol/l, calcium 2 mmol/l

Question 4

Ringer lactate/Hartman’s solution/ compound sodium lactate Bp

Answer 4

pH 5.0-7.0, formula per 1000 ml: sodium chloride 6.0 g+potassium chloride 0,4 g+ calcium chloride dihydrate 0,27 g+sodium lactate 3,2 g+water for injection. Sodium 131 mmol/l, chloride 111 mmol/l, bicarbonate 29 mmol/l, potassium 5 mmol/l, calcium 2 mmol/l

Question 5

Class 1 hemorrhage

Answer 5

Blood volume loss of up to 15 percent, not change in bp, pulse pressure, respiratory rate

Question 6

Class 2 hemorrhage

Answer 6

15-30 percent blood volume loss, manifested clinically as tachycardia (hr 100-120), tachypnea (rr 20-24), decreased pulse pressure, although systolic BP changes minimally.

Question 7

Class 3 hemorrhage

Answer 7

30-40 percent blood volume loss, significant drop in BP and change in mental status. Hypotension (SBP<90 mmHg or drop in BP greater than 20-30% of measurement. HR>120, RR elevated, urine output is diminished, capillary refill delayed.

Question 8

Class 4 hemorrhage

Answer 8

> 40% blood blood volume loss, hypotensive (SBP>90 mmHg)., pulse pressure is narrowed (<25 mmHg) tachycardia (>120 beats per minute). Urine output in minimal or absent. Capillary refill is delayed

Question 9

Plasma

Answer 9

Sodium 135-145 mEq/l, potassium 3.5-5.0 mEq/l, Calcium 2.2-2.6 mEq/l, 4.4-4.2 mg/dL, 1,1-1,3 mmol/l; magnesium 0.8-1.0 mEq/l, 1,0-1,2 mf/dL, 0.4-0.5 mmol/l, chloride 94-111 mEq/l, lactate 1-2 mEq/l, osmolarity 275-295

Question 10

Emergency reversal of anticoagulation from warfarin for life -treatening hemorrhage in adults

Answer 10

1. Give 4-factor protrombin complex concentrate (4F PCC - factors II, VII, IX, X, protein S and protein C) 1500 to 2000 unit IV, check INR 15 minutes after, INR>1,5, give additional 4F PCC + vitamin K 10 mg IV over 10 to 20 min.
2. 3F PCC - factors II, IX, X 1500 to 2000 unit IV, check INR 15 minutes after, INR>1,5, give additional 3F PCC + factor VIIa 20 mcg/kg or FFP 2 units IV rapid infusion + vitamin K 10 mg IV over 10 to 20 min.
   3 Give FFP unit rapid infusion Check INR 15 minutes, if INR>1,5 +2 additional units of FFP IV, may wish to administer loop diuretic if volume overload + vitamin K 10 mg IV over 10 to 20 min.

Question 11

Life -treatening or imminently fatal bleeding - treatment from dabigatran

Answer 11

1. Idarucizumab,
2. activated protrombin complex concentrate (PCC)-eg. FEIBA (factor eight inhibitor bypassing activity)
3. anti fibrinolytic agent (eg. Tranexamic acid, epsilon -aminocapronic acid)
4. Oral activated charcoal (if last within prior two hours)
5. Anticoagulant discontinuation
6. Hemodialysis
7. RBC transfusion if needed for anemia
8. Platelet transfusion if needed for thrombocytopenia or impaired platelet function (eg. due to aspirin
9. Surgical/endoscopic intervention if appropriate.

Question 12

Life - threatening or imminently fatal bleeding from Rivaroxaban, Apixaban, edoxaban

Answer 12

1. Andexanet alfa (AndexXa) or a 4-factor unactivated PCC (Kcentra)
2. anti fibrinolytic agent (eg. Tranexamic acid, epsilon -aminocapronic acid)
3. Oral activated charcoal (if last within prior two hours)
4. Anticoagulant discontinuation
5. RBC transfusion if needed for anemia
6. Platelet transfusion if needed for thrombocytopenia or impaired platelet function (eg. due to aspirin
7. Surgical/endoscopic intervention if appropriate.

Question 13

Minor bleeding from Dabigatran

Answer 13

1. Local hemostatic measures
2. Possible anticoagulant discontinuation ( half -life for normal renal function: 12-17 hours)
3. Possible anti fibrinolytic agent eg tranexamic acid, epsilon -aminocapronic acid

Question 14

Minor bleeding with Rivaroxaban Apixaban and edoxaban

Answer 14

1. Local hemostatic measures
2. Possible anticoagulant discontinuation ( half -life for normal renal function: Apixaban 8-15 hours, Rivaroxaban 5-9 hours, edoxaban 6-11 hours)
3. Possible anti fibrinolytic agent eg tranexamic acid, epsilon -aminocapronic acid