Major Haemorrhage (bsh 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




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

  • 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

Hospital Transfusion Committee (HTC) oversee protocol development and implementation

Hospital Transfusion Team (HTT) support all activities essential for effective use of the protocol


MDT Required

  • Switchboard

  • Porters

  • Transfusion Lab Staff

  • Senior nurse / midwife / clinician

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

  • Haematologist


Transfusion Support



  • 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 2015 and RECESS 2015 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 2015 study – no difference 1:1:1 vs 1:1:2 of FFP:PLT:RBC



  • 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



  • 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

  • WOMAN 2017 - Tranexamic acid reduces deaths from post-partum haemorrhage


GI Bleeding

  • Restrictive strategy associated with improved outcomes



  • Acute Traumatic Coagulopathy poorly defined but distinct syndrome in trauma

  • TXA now administered at the roadside



  • 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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