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