Major Haemorrhage (2015)

Massive blood loss definitions:

Loss of one blood volume in 24 hours

50% blood volume loss in 3 hours

Blood loss of 150ml/min

 

Major Haemorrhage definition:

Bleeding that results in HR >110 and/or Sys BP <90

 

Intro

 

-       CRASH-2 Study lead to widespread uptake of TXA in major haemorrhage

o   Death within 4 weeks of traumatic injury was reduced by 9% vs placebo

-       Small no. of patients continue to die due to delays in blood product provision

 

Organisational Principles

 

-       Hospitals must have a major haemorrhage protocol

-       HTC oversee protocol development and implementation

-       HTT support all activities essential for effective use of the protocol

 

-       MDT Required

o   Switchboard

o   Porters

o   Transfusion Lab Staff

o   Senior nurse / midwife / clinician

o   Stop the bleeding – radiology, surgery, obstetrics, endoscopy

o   Haematologist

 

Transfusion Support

 

Principles

-       Supports the primary aim of local control of bleeding

-       Accurate documentation required to fulfill legal obligation for traceability

-       Blood warmers and pressure infusers should be available in relevant clinical areas

-       If <3 hours since traumatic injury, give TXA 1g IV bolus, followed by 8 hour infusion

 

Upfront Order

-       Red Cells 4-6 units

-       FFP 15-20ml/kg

-       Platelets 1 unit

-       Cryoprecipitate 2 units

 

Coag Tests

-       PT possibly more sensitive than APTT to coagulation factor deficiency in trauma

-       Clauss fibrinogen should be used (but false high levels with use of colloid fluids)

-       Use of ROTEM / TEG reduces bleeding but no change in mortality / morbidity

 

Red Cells

-       Oxygen-carrying capacity + prompt axial flow and margination of plasma/platelets

-       Target 70-90g/l

-       Red cell Tx usually becomes necessary after loss of 30-40% of blood vol (1500ml)

-       Blood warmers prevent hypothermia

-       Does age of red cells matter? ABLE and RECESS trials say no

-       Consider remote blood fridges in large institutions

-       Consider cell salvage

 

Fresh Frozen Plasma

-       1:1 ratio with red cells based largely on military studies

-       Ratio between 1:1 – 1:2 of FFP:RBC until bleeding controlled

-       PROPPR study – no difference 1:1:1 vs 1:1:2 of FFP:PLT:RBC

 

Cryoprecipitate

-       1 donation is pooled with five others to produce a 5-unit pool

-       A typical adult dose is 2 pools (= 10 donations)

-       FGN level <1 is likely after 1-1.5 times blood volume replacement

 

Platelets

-       Thrombocytopenia typically occurs after 1.5 times blood volume replacement

-       1 donation is pooled with four others to produce a 4-unit pool

-       One adult dose = one 4-unit pool or a single apheresis unit

 

Specific Scenarios

 

Obstetric haemorrhage

-       PPH still a leading cause of obstetric death

-       Maintain FGN >2.0

-       TXA? – WOMAN trial awaiting publication

 

GI Bleeding

-       Restrictive strategy associated with improved outcomes

 

Trauma

-       Acute Traumatic Coagulopathy poorly defined but distinct syndrome in trauma

-       TXA now administered at the roadside

 

Paediatrics

-       Not little adults

-       Principles the same but anatomy & physiology differ, not just size and height

 

Example of a Major Blood Loss Protocol

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