Massive blood loss; hemorrhage

1. Description of the problem

Massive blood loss can lead to organ damage and possibly death and therefore is a medical emergency requiring immediate diagnosis and treatment.

There are different definitions for massive blood loss. For example, loss of at least one blood volume (approximately 10 units RBCs in a 70-kg patient) in the first 12 hours is one definition. Some consider it to be loss of 50% of the total blood volume within 1-3 hours. The definition for massive blood loss will depend to some extent on the specific facts for a given patient. For example, a smaller blood loss (e.g. 1 liter) might be considered massive or clinically very significant in a patient who refuses medically indicated blood products (e.g. Jehovah’s Witness).

One must simultaneously attempt to: 1) identify the source of bleeding and control it as quickly as possible, and 2) prepare and transfuse the patient as appropriate to maintain hemodynamic stability and avoid organ injury.

2. Emergency Management

Treatment of massive blood loss is VERY labor intensive. Make sure that you call for and obtain adequate help, as it sometimes takes at least 3 or 4 clinicians (i.e. MD, nurses, midlevels) and technicians to do all of the activities listed below. Note that these activities need to be done in most cases in parallel, NOT in series.

A) Identify the source of bleeding and control it as quickly as possible. In many cases this will involve calling for help urgently from other clinicians, e.g. a surgeon in the case of likely surgical bleeding or a gastroenterologist in the case of a major GI bleed. This identification of the source of bleeding needs to be done at the same time that one is preparing to and resuscitating the patient (#2). Remember that during acute bleeding (without fluid administration) the hematocrit/hemoglobin is not likely to decrease.

B) Preparation for blood transfusion/fluid resuscitation includes the following:

Ensure that there is adequate IV access (large-bore peripheral IVs may be better in some cases than smaller-bore central venous catheters).
Insert an intra-arterial catheter if not already available. Remember that you can withdraw venous blood from many IV catheters for determination of hemoglobin/hematocrit, calcium lactate, and other assays until an arterial catheter is available.
Ensure that at least one fluid warmer is connected to warm blood products and other fluids. Depending on the institution and magnitude of the bleeding it may be prudent to set up a Level One or Belmont Rapid Infuser. Ideally convective warming should also be used.
Call the Blood Bank/Transfusion Services and let them know that you are caring for a patient with massive bleeding and will be sending them samples and requests for blood.
If not already available/done, send a stat Type and Screen.
If the patient has acute life-threatening blood loss and cross-matched blood is not immediately available, ask the Blood Bank to send emergency release (type O) blood or type-specific (but not cross-matched) blood. Request cross match for an appropriate number of blood products. In some cases this will be 6 units RBCs, 4 units FFP, and 1 pheresis or multipack of platelets. However, the number requested will depend on many factors. For example, if the patient has known thrombocytopenia, then it may be prudent to request more platelets. Or if there is a major surgical source of bleeding (e.g., aortic injury), then it may be prudent to request more (e.g. 10 units) RBCs. Or if it is known that the patient has a major factor deficiency, then it may be prudent to request more FFP and/or cryoprecipitate. There is interest lately in the trauma community in favor of a 1:1 FFP to RBC ratio during massive transfusion, but the benefit of this strategy has not been proven yet.
Send off stat labs (CBC, Chem7, PT, PTT, fibrinogen) as changes in these values over time can be helpful. However, it is recognized that in many cases transfusion is empiric as decisions need to be made before all appropriate lab results are available. It should be recognized that in the early stages it may be useful to obtain frequent labs (e.g. every 30-60 minutes) during the first1 to 2 hours.

C) In some cases it may be appropriate to intubate the patient’s trachea with an ETT (e.g. if the patient is very unstable and going directly to the OR). However, laryngoscopy/intubation in and of itself can be harmful if sedative/hypnotic drugs are administered since many of these drugs decrease cardiac output and blood pressure. Consider the use of ketamine if intubation is needed in this setting. In addition, intubation will generally be followed by the use of positive-pressure ventilation, which will decrease venous return and can decrease cardiac output and blood pressure. Therefore, in some instances it may be preferable to not intubate the patient unless it is deemed necessary. In most cases a Foley urinary catheter should be inserted.

D) In most cases of massive bleeding it will be helpful to obtain frequent arterial blood gas (ABG) analysis (e.g. every 30 minutes for the first 2 hours). Most of these patients will develop a metabolic acidosis, and the acidemia may require correction with either increased minute ventilation and/or administration of sodium bicarbonate. However, administration of sodium bicarbonate is controversial as there is some evidence that acidemia may be beneficial for the patient in this setting. Some clinicians will not correct acidemia unless the pH is lower than approximately 7.2. Assessment of potassium and ionized calcium from the ABG is also important since administration of older RBCs can result in hyperkalemia and administration of citrated RBCs can depress ionized calcium levels. During rapid administration of FFP (e.g. 500 ml over 30 minutes) the ionized calcium will decrease significantly and should be measured and supplemented as appropriate.

Recombinant Factor VIIa administration can be considered where appropriate. However, its use should not be a replacement for routine administration of RBCs and components (FFP, platelets, cryo).

3. Diagnosis

Pathophysiology

Epidemiology

Special considerations for nursing and allied health professionals.

As described above, due to the labor-intensive nature of diagnosis and treatment of massive bleeding, nurses and allied health professionals (e.g., technicians) play a major role in this medical emergency. Their importance cannot be overstated. To this end it is helpful for hospitals, including operating rooms and ICUs, to develop guidelines on the diagnosis and treatment of massive bleeding.

What's the evidence?

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