Management

Question 1

What is the transfusion management of major haemorrhage?

Answer 1

1. Recognise blood loss
2. Resuscitate, call for help
3. Stop the bleeding - TXA, PCC
4. Team approach - emergency runner between lab and clinical area
5. Communicate with lab early and clearly
6. Know where emergency O neg is
7. Massive haemorrhage packs
8. Monitor coag tests + move to goal directed therapy

Question 2

How do you stop the bleeding?

Answer 2

• Local measures e.g. pressure, tourniquets
• Early intervention - damage limitation
• Reverse anticoagulants e.g. PCC
• Tranexamic acid - stabilise blood clotting (within 1 hr)
• Blood samples: FBC, U+E, LFT, Ca, PT, APTT, fibrinogen, crossmatch
• Emergency runner to take samples to lab

Question 3

In a major haemorrhage what needs to be communicated with the lab?

Answer 3

• State major haemorrhage adult/child/location
• Request RBC, FFP, platelets
• Decide on use of emergency O neg uncrossmatched blood or group specific blood (if possible to wait for 15 mins)

Question 4

What is in a major haemorrhage pack 1?

Answer 4

• 4 units red cells
• 4 units FFP (fresh frozen plasma)

Question 5

What is in a major haemorrhage pack 2?

Answer 5

• 4 units red cells
• 4 units FFP
• 1 dose platelets
• 2 packs cryoprecipitate

Question 6

What results are you aiming for during a major haemorrhage?

Answer 6

• Fibrinogen >1.5g/L
• PT ratio <1.5
• APTT ratio <1.5
• Hb 80-100g/L
• Platelets >75x10^9/L

Question 7

What need to happen when you stand down from a major haemorrhage?

Answer 7

• Let lab know
• Once under control, the patient will be at risk of thrombosis and will require thromoprophylaxis

Question 8

What is the treatment for PVD?

Answer 8

• Stop smoking
• Antiplatelet therapy e.g. aspirin
• BP control
• Cholesterol reduction - <5 or 25%
• Regular exercise
• Weight loss
• Diabetes

Question 9

What is the treatment for symptomatic cerebrovascular disease?

Answer 9

• Surgical - carotid endarterectomy

- Indications for surgery - symptomatic patients in last 6 months, >70% stenosis ICA

Question 10

What is the treatment for asymptomatic cerebrovascular disease?

Answer 10

• Medical therapy
• Operation in selected circumstances - no real evidence for benefit over all (50 NNT), younger patients, CABG/aortic surgery, cerebral perfusion concerns

Question 11

What is the treatment for aneurysms?

Answer 11

• Symptoms: intervene regardless of size
• Under 5.5cm: surveillance scan
• Over 5.5cm: intervene on risk balance - open surgery (plastic graft) or endovascular surgery (reline aorta)

Question 12

What is the management of hypovolaemic shock?

Answer 12

• ABC
• Administer oxygen
• IV fluids
• Treat cause
• Resuscitation begins concurrently or ahead of diagnostic process
• Aiming to prevent irreversible organ injury and failure

Question 13

What is the treatment of coagulation abnormalities in a major haemorrhage patient?

Answer 13

• Keep warm
• Treat cause e.g. sepsis
• Reverse drugs e.g. warfarin (antiplatelet agents)
• Reduce fibrinolysis
• Shock packs

Question 14

What is the immediate management of ruptured AA?

Answer 14

• Initiate major haemorrhage protocol

- Call vascular surgeons and ICU anaesthetists for urgent surgery and transfer to ICU