Hemorrhage

Management

Major Hemorrhage

Massive hemorrhage protocol
- When to activate:
  - GI hemorrhage: 2-4 units uncrossmatched RBCs; if poor response, activate massive hemorrhage protocol
  - Non-GI hemorrhage:
    - If shock index 1-1.3, give 2-4 units uncrossmatched RBCs; if poor response, activate massive hemorrhage protocol
    - If shock index ≥1.4, CAT ≥3, or RI ≥4, then activate massive hemorrhage protocol
- Once activated:
  - 4 units pRBC (± tranexamic acid, below)
  - 4 units pRBC plus 4 units plasma
  - 4 units pRBC plus 2 units plasma
  - Monitor for electrolytes abnormalities (hyperkalemia and hypocalcemia) and consider calcium chloride 1 g or calcium gluconate 3 g for every 4 units of pRBC
Tranexamic acid
- For postpartum hemorrhage: tranexamic acid 1 g IV once, repeat at 30 minutes if ongoing bleeding
- For recent (<3 h) traumatic hemorrhage: tranexamic acid 2 g IV once, ideally within 60 min of injury
- No GI bleeds, it should not be used routinely
Monitoring and targets
- Repeat blood draws every 30 to 60 minutes
- GI hemorrhage:
  - Hemoglobin >70 g/L
  - INR <1.8 (non-cirrhosis)
  - Platelets >50 x10E9/L (non-cirrhosis)
  - Fibrinogen >1.5 g/L
- Non-GI hemorrhage
  - Hemoglobin 80 to 120 g/L
  - INR <1.8
  - Platelets >50 x10E9/L
  - Fibrinogen >1.5 g/L
Reverse anticoagulation
- Warfarin: vitamin K 10 mg IV once; PCC 1000 IU (INR 1.5-3) or 2000 IU (INR 3-5 or unknown) or 3000 IU (INR >5)
- Dabigatran: idarucizumab 5 g IV once
- Factor Xa inhibitors: PCC 2000 IU once (or andexanet alpha, if available); repeat PCC at 1 h if ongoing hemorrhage