Massive Haemorrhage Flashcards
what is a massive haemorrhage
defined by blood loss: -one blood volume in 24hrs -50% in 3 hours -150ml/minute in obstetrics: -minor= 500-1000 -major= >1000
defined by clinical situation:
- bleeding which leads to HR >110 and/or systolic BP <90
- bleeding which has already prompted use of emergency O Rh(D) negative red cells
how long till blood sample gets to lab until products on way to ward
15 mins
what urgent blood tests should be done in the major haemorrhage protocol
FBC, coag screen, fibrinogen, crossmatch, U&Es, calcium
what will the blood bank issue in the major haemorrhage protocol
4 units Red cells
4 units FFP
1 unit platelets
what is the initial steps to be taken after initiating the major haemorrhage protocol
send urgent blood samples resuscitate patient w/ ABCDE large bore IV access IV fluids call for senior help tranfuse red cells/ FFPs. platelets
what should you do if ongoing bleeding after initial transfusion
repeat blood samples
transfuse further RBC and FFP at ratio 2:1
(in trauma 1:1)
cryoprecipitate if fibrinogen <1g/L (<2g/L in obstetric haemorrhage)
consider further platelets
do women in pregnancy have a higher or lower fibrinogen level
higher
what blood results do you want to maintain in major haemorrhage
Hb >80
APTT and PT ratio <1.5
platelets >50
fibrinogen >1.5 (>2 in obstetrics)
what is the role of red cell transfusion
maintain tissue oxygenation
what is the role of FFP (fresh frozen plasma) in transfusion
replaces coagulation factors and helps maintain coagulation close to normal
what is the role of cryoprecipitate transfusion
replaces fibrinogen
what ratio of components do you want to replace blood products in in transfusion
2 RBC : 1 FFP
1:1 in trauma
what must you consider once bleeding is controlled
thromboprophylaxis (coagulation systems activated in big bleeds- esp in obstetrics when risk of VTE much higher anyway)
what is the most common cause of PPH
uterine atony
what is the blood flow to the uterus
700 ml per min
what is the specific management for PPH
• Tranexamic acid as per the WOMAN study
• Consider the use of cryoprecipitate early, particularly if fibrinogen
<2g/L
• Obstetric
i. Pharmacological- oxytocin, ergometrine
ii. Mechanical- rubbing uterus, empty bladder with catheter
iii. Surgical- uterine balloon tamponade, haemostatic suturing, artery
ligation, interventional radiology to embolise, hysterectomy
• Importance of thromboprophylaxis once bleeding is controlled.
what drug is given pre hospital to trauma haemorrhages
tranexamic acid
what do patient with variceal bleeds often need
often have coagulopathy so need FFP to bring up clotting levels
what specific management for ruptured AAA
support until surgery or interventional radiology can stop bleed
imaging CT/ CT angiogram to confirm Dx, surgery, vasopressors, inotropes
how do you monitor response to transfusion
Hb levels
FBC and coagulation screen every 30-60 minutes
until bleeding controlled
Obs after first transfusion, then every 15 for first hour: BP, temp, HR, RR, O2 sats, AVPU
Fibrinogen levels (want them >1.5, >2 for pregnant women)
Clotting factors: PT and APTT
Platelet count
Clinical exams- signs of shock, pale, clammy
bleeding stopped?
Urine output
what can you use if you suspect a pelvic #
pelvic binder
what specific management for trauma haemorrhages
Tranexamic acid for bleed Imaging Pressure and tornique if external bleed Surgical embolization's or exploration Thromboprophylaxis
what specific management for variceal bleeding
Pharmacological- terlipressin, vitamin K, antibiotics
Blood component- patient may have pre-existing coagulopathy and
therefore require more FFP/ cryo to correct this
Endoscopic- banding of varices/ sclerotherapy
Sengstaken-Blakemore tube
TIPPS (bypass procedure to reduce portal pressure)
balloon tamponade
