Case 120 – Summary!

Thank you for everyone’s contributions this week. We discussed the management of a 57 year old lady who was suffering a major haemorrhage secondary to a road traffic accident.

The key points of managing a major haemorrhage (from haem perspective) are highlighted below:

  1. Identify Major Haemorrhage
    1. Early recognition essential to enable prompt provision of blood products
    2. Definitions:
      1. Bleeding which leads to heart rate >110bpm +/- systolic BP <90mmHg (NB be aware of patients baseline HR / SBP as individuals may be significantly compromised at the above parameters if their baseline levels vary from the general population)
      2. Loss of 1 blood volume in 24 hours / 50% blood volume in 3 hours / 125ml blood loss in 1 minute (NB these definitions are generally considered less useful as often detected retrospectively)
  1. Activate major haemorrhage protocol
    1. All hospitals within the UK should have a protocol
    2. Typically involves senior clinician, senior nurse, anaesthetist, transfusion lab, porter
    3. Ideally the team leader should designate one member of staff to liaise with the haematology lab

 

  1. Initial Management
    1. ABC approach and local control of bleeding
    2. Bloods:
      1. FBC, coag and clauss fibrinogen, biochem
      2. Group and save (x2 different times)
        1. Minimum identifiers: name, DoB, unique patient identifier number
        2. If unknown patient: Unique patient identifier number and gender
      3. Transfusion support (see below)
      4. Ascertain if on anti-platelets / anticoagulation (if possible)

 

  1. Transfusion Support
    1. Urgent blood / blood component transfusion. Major haemorrhage packs should be available as part of the major haemorrhage protocol. The documented ‘packs’ below are a guide and will vary slightly between hospitals such as 1 pool platelets may be available in pack. Need to switch to group specific / cross-matched packed red cells (PRCs) asap. Use cell salvage if available. Ongoing PRCs and components should be guided by blood results and near patient tests as soon as available alongside the ongoing clinical situation.
    2. Pack 1 of major haemorrhage pack
      1. PRCs and FFP in 1:1 ratio or 2:1 ratio (based on PROPPR trial – which improved deaths from bleeding but note no benefit in overall survival)
      2. 4 units PRCs
        1. If female of child bearing potential (<50 yrs) give Group O Rh D-ve Kell-ve
        2. If adult male or female >50yrs can consider Group O Rh D+ve
        3. Switch to group specific as soon as possible
      3. 4 units FFP
        1. Ideally Group AB but often in short supply in which case Group A (negative for high-titre anti-B)
    3. Pack 2 of major haemorrhage pack
      1. PRCs and FFP in 1:1 or 2:1 ratio (4 units PRCs : 4 units FFP)
      2. 1 pool platelets (consider giving platelets earlier if known to be on anti-platelets)
      3. Consider cryoprecipitate
    4. Transfusion based on blood results / near patient tests
      1. Aim to do traditional coagulation tests (PT, APTT, clauss fib) approximately every 30 mins. Be aware that these tests are not real-time so don’t represent the current clinical picture
      2. TEG / ROTEM provide real time results but should be used alongside traditional coag tests.Aim parameters
        1. Falling Hb: PRCS
        2. PTr / APTTr >1.5 : FFP 15-20ml/kg
        3. Clauss fibrinogen <1.5 (2 if obstetric haemorrhage) : 2 ppols of cryoprecipitate
        4. Platelets <50 : 1 pool platelets
  1. Pharmacological agents
    1. Tranexamic acid
      1. If trauma <3hrs / or risk of major haemorrhage / or not contraindicated as per CRASH 2 trial which demonstrated increased overall survival with TXA use. Give 1g TXA bolus then further 1g over 8 hours.
    2. Reversal agents for anti-coagulation (i.e protamine for heparin, praxbind for dabigatran)
  1. Other supportive measures
    1. Optimisation of hypothermia (aim >36.5C), acidosis, hypocalcaemia to reduce coagulopathy.
  1. Measures post major haemorrhage
    1. When bleeding has ceased – DEACTIVATE PROTOCOL (inform blood bank)
    2. Return unused stock to blood bank
    3. Monitor for complications from transfusions such as TACO
    4. Consider VTE prophylaxis when considered safe from bleeding perspective

 

References:

  1. Hunt BJ et al. A practical guideline for the haematological management of major haemorrhage. British Journal of Haematology. 170 (6). 788-803. 2015.
  2. Norfolk D. Handbook of Transfusion medicine 5th Edition. TSO. 2013.

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