Clinical features and diagnosis Top
Local symptoms of bleeding (hemorrhage) depend on its location and are not always overt. (Locations include, among others, the gastrointestinal [GI] tract [see Gastrointestinal Bleeding] and wounds due to trauma.) Blood pressure may not drop until 750 to 1500 mL of blood is lost. In the early stages of bleeding, it is sometimes important to compare the blood pressures and heart rates measured in supine and standing positions. An orthostatic drop in blood pressure ≥10 mm Hg and increase in pulse rate ≥20 beats/min suggests hypovolemia. A blood loss up to 1500 mL is usually accompanied by subtle changes in mental status, while losing half of the blood volume (2000-2500 mL) is associated with a significantly altered mental status (usually loss of consciousness). A decrease in hematocrit, hemoglobin levels, and red blood cell counts usually occurs ≥1 to 3 (4) hours after the blood loss.
1. Stop the bleeding, if possible. When necessary, refer the patient for a specialist minimally invasive surgery (eg, endoscopy in the case of GI bleeding) or radiologic assessment for embolization.
2. Continue fluid resuscitation with crystalloids (eg, ~3 mL for every 1 mL blood lost) or colloids (eg, ~1 mL for every 1 mL of blood lost) only until packed red blood cells (PRBCs) are available for transfusion (see Shock). Once blood products are available, they are the best resuscitative fluid to use in hemorrhagic shock. We suggest a target systolic blood pressure of 80 to 90 mm Hg (mean arterial pressure, 40 mm Hg) until major bleeding has been stopped in the initial phase following trauma without brain injury.Evidence 1Weak recommendation (benefits likely outweigh downsides, but the balance is close or uncertain; an alternative course of action may be better for some patients). Low Quality of Evidence (low confidence that we know true effects of the intervention). Quality of Evidence lowered to low due to imprecision and inconsistency of results. Spahn DR, Bouillon B, Cerny V, et al. Management of bleeding and coagulopathy following major trauma: an updated European guideline. Crit Care. 2013 Apr 19;17(2):R76. doi: 10.1186/cc12685. Review. PubMed PMID: 23601765; PubMed Central PMCID: PMC4056078.A mean arterial pressure ≥80 mm Hg should be maintained in patients with combined hemorrhagic shock and severe traumatic brain injury (Glasgow Coma Scale, ≤8) in order to maintain cerebral perfusion pressures.
3. Collect blood samples for cross-matching. Request blood group typing if the group cannot be quickly and reliably established on the basis of medical records. Order and transfuse PRBCs (see Blood and Blood Product Transfusion). In patients with massive hemorrhages, do not wait for the results of the cross-matching and transfuse 0 Rh- blood before compatible blood arrives. If the shock persists, do not allow for a hematocrit fall <30%. In patients with severe blood loss, supplement the PRBC transfusions with the administration of fresh frozen plasma (FFP) and consider platelet transfusion as well as administration of cryoprecipitate (as a reasonable example, supplement the transfusion of >2 U of PRBCs with 1 U of FFP for every 2 U of PRBC and 1 U of platelets for 5 U of PRBC; in massive bleeding, it is advised to supplement transfusions of PRBCs with FFP or fibrinogen from the beginning of treatment). In the case of coagulopathy, consider FFP, cryoprecipitate, and platelet transfusions. In massive bleeding that cannot be controlled by surgical procedures, blood transfusion, or tranexamic acid (see below), consider administration of recombinant factor VIIa concentrate as rescue treatment.
4. Prevent and treat complications of massive bleeding and transfusion, including hypothermia, acidosis, and hypocalcemia (these impair blood coagulation).
6. In patients with severe hemorrhage following trauma, we recommend the administration of intravenous tranexamic acid (loading dose 1 g over 10 minutes, then 1 g over 8 hours).Evidence 2Strong recommendation (benefits clearly outweigh downsides; right action for all or almost all patients). High Quality of Evidence (high confidence that we know true effects of intervention). Morrison JJ, Dubose JJ, Rasmussen TE, Midwinter MJ. Military Application of Tranexamic Acid in Trauma Emergency Resuscitation (MATTERs) Study. Arch Surg. 2012 Feb;147(2):113-9. doi: 10.1001/archsurg.2011.287. Epub 2011 Oct 17. PubMed PMID: 22006852. CRASH-2 trial collaborators, Shakur H, Roberts I, Bautista R, et al. Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo-controlled trial. Lancet. 2010 Jul 3;376(9734):23-32. doi: 10.1016/S0140-6736(10)60835-5. Epub 2010 Jun 14. PubMed PMID: 20554319.
7. Other management procedures: see Shock.
For rapid fluid resuscitation and blood transfusions, use large-bore peripheral venous catheters (preferably ≥1.8 mm [≤16 gauge]; establish 2 separate IV lines) as these allow for higher infusion rates compared to central lines. If peripheral access is not possible, a large bore central line (such as employed for renal replacement therapies or angiography/pacing [vascular sheaths]) should be used.