Massive Haemorrhage

Question 1

what is a massive haemorrhage

Answer 1

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

Question 2

how long till blood sample gets to lab until products on way to ward

Answer 2

15 mins

Question 3

what urgent blood tests should be done in the major haemorrhage protocol

Answer 3

FBC, coag screen, fibrinogen, crossmatch, U&Es, calcium

Question 4

what will the blood bank issue in the major haemorrhage protocol

Answer 4

4 units Red cells
4 units FFP
1 unit platelets

Question 5

what is the initial steps to be taken after initiating the major haemorrhage protocol

Answer 5

send urgent blood samples
resuscitate patient w/ ABCDE
large bore IV access
IV fluids 
call for senior help 
tranfuse red cells/ FFPs. platelets

Question 6

what should you do if ongoing bleeding after initial transfusion

Answer 6

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

Question 7

do women in pregnancy have a higher or lower fibrinogen level

Answer 7

higher

Question 8

what blood results do you want to maintain in major haemorrhage

Answer 8

Hb >80
APTT and PT ratio <1.5
platelets >50
fibrinogen >1.5 (>2 in obstetrics)

Question 9

what is the role of red cell transfusion

Answer 9

maintain tissue oxygenation

Question 10

what is the role of FFP (fresh frozen plasma) in transfusion

Answer 10

replaces coagulation factors and helps maintain coagulation close to normal

Question 11

what is the role of cryoprecipitate transfusion

Answer 11

replaces fibrinogen

Question 12

what ratio of components do you want to replace blood products in in transfusion

Answer 12

2 RBC : 1 FFP

1:1 in trauma

Question 13

what must you consider once bleeding is controlled

Answer 13

thromboprophylaxis (coagulation systems activated in big bleeds- esp in obstetrics when risk of VTE much higher anyway)

Question 14

what is the most common cause of PPH

Answer 14

uterine atony

Question 15

what is the blood flow to the uterus

Answer 15

700 ml per min

Question 16

what is the specific management for PPH

Answer 16

• 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.

Question 17

what drug is given pre hospital to trauma haemorrhages

Answer 17

tranexamic acid

Question 18

what do patient with variceal bleeds often need

Answer 18

often have coagulopathy so need FFP to bring up clotting levels

Question 19

what specific management for ruptured AAA

Answer 19

support until surgery or interventional radiology can stop bleed
imaging CT/ CT angiogram to confirm Dx, surgery, vasopressors, inotropes

Question 20

how do you monitor response to transfusion

Answer 20

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

Question 21

what can you use if you suspect a pelvic #

Answer 21

pelvic binder

Question 22

what specific management for trauma haemorrhages

Answer 22

Tranexamic acid for bleed 
Imaging 
Pressure and tornique if external bleed 
Surgical embolization's or exploration 
Thromboprophylaxis

Question 23

what specific management for variceal bleeding

Answer 23

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