💉 "Bleeders come first" — Haemorrhage kills quickly and may be hidden or from multiple sites. Early recognition, activation of the major haemorrhage protocol, and coordinated team action saves lives.

🚨 Initial Approach (Give Group O blood if immediate need and group unknown)
📢 Declare major haemorrhage; get Anaesthetic, Surgical, Obstetric, and Radiology support. 🫁 ABC: Oxygen, airway secured. Insert 2 large-bore IV cannulas (14–16G) or IO if not possible. 🧪 Send bloods: FBC, clotting, fibrinogen, crossmatch, ROTEM/coag monitoring. 🩸 Control bleeding: Elevate site, apply pressure/tourniquet, surgical or IR intervention if needed. 💧 Give IV crystalloid (250 mL boluses, pressure bag) only until blood available. 💊 Give Tranexamic acid: 1 g IV over 10 min (then 1 g over 8 h). Reverse anticoagulants. Correct hypocalcaemia. ➡️ Blood loss >40%: 4U RBCs via fluid warmer (target Hb >80 g/L) + 4 FFP + 1 platelet pool. 🚻 Insert catheter, monitor VBG, liaise with ICU early. 🔑 Targets if bleeding: PLTs >100 ×10⁹/L, Hb >80 g/L, Fibrinogen >1.5 g/L, PT/APTT <1.5 × normal.

🚨 Initial Approach (Give Group O blood if immediate need and group unknown)

📢 Declare major haemorrhage; get Anaesthetic, Surgical, Obstetric, and Radiology support.
🫁 ABC: Oxygen, airway secured. Insert 2 large-bore IV cannulas (14–16G) or IO if not possible.
🧪 Send bloods: FBC, clotting, fibrinogen, crossmatch, ROTEM/coag monitoring.
🩸 Control bleeding: Elevate site, apply pressure/tourniquet, surgical or IR intervention if needed.
💧 Give IV crystalloid (250 mL boluses, pressure bag) only until blood available.
💊 Give Tranexamic acid: 1 g IV over 10 min (then 1 g over 8 h). Reverse anticoagulants. Correct hypocalcaemia.
➡️ Blood loss >40%: 4U RBCs via fluid warmer (target Hb >80 g/L) + 4 FFP + 1 platelet pool.
🚻 Insert catheter, monitor VBG, liaise with ICU early.
🔑 Targets if bleeding: PLTs >100 ×10⁹/L, Hb >80 g/L, Fibrinogen >1.5 g/L, PT/APTT <1.5 × normal.

📖 About

Uncontrolled haemorrhage is rapidly fatal.
IV fluids do not carry oxygen and dilute clotting factors → after 1 L crystalloid, switch to blood (O− if urgent).

🧭 Algorithm

🩺 Causes of Bleeding

🩻 Vessel wall: collagen diseases, hereditary haemorrhagic telangiectasia, senile purpura, steroids, trauma (e.g. marching purpura), severe infection.
🧬 Clotting system: warfarin, heparin, DIC, haemophilia A/B, von Willebrand disease.
🧩 Platelets: ITP, vWD, aspirin (irreversible COX inhibition), marrow failure, malignancy.

📉 Hypovolaemic Shock Severity

⚡ Pathophysiology

🧪 Investigating for Medical Causes

📊 FBC: Platelets → thrombocytopenia?
⏱️ PT: Prolonged → deficiency of II, V, VII, X → give IV Vitamin K or Octaplex/Beriplex.
⏱️ APTT: Prolonged → multiple factor deficiency → give FFP.
🧵 Fibrinogen: Low → give cryoprecipitate.
🧪 Thrombin time: Abnormal fibrinogen.
🔍 FDP/D-dimer: Suggests DIC.

💡 Principles of Blood Loss Management

Balance two priorities:
- 💓 Circulation & perfusion → fluids help maintain BP but dilute clotting.
- 🧬 Coagulation preservation → avoid over-dilution & hypothermia.
❌ Avoid excessive crystalloids (↑mortality). Use early blood products.
🟥 RBCs are first-line. If instability → activate major haemorrhage protocol via switchboard.

📊 Major Haemorrhage Definitions

Loss >1 blood volume in 24 h (~70 mL/kg, >5 L in 70 kg adult).
≥50% blood volume lost in <3 h.
Bleeding >150 mL/min.
Clinically: SBP <90 mmHg or HR >110 bpm with ongoing bleeding.

🩸 Replacement Targets

Hb ↓ → transfuse RBCs.
PT >1.5 → give FFP (15–20 mL/kg).
Fibrinogen <1.5 g/L → give cryoprecipitate (2 pools).
Platelets <75 ×10⁹/L → transfuse 1 ATD platelets.

🧃 Types of Blood Available

🟥 O Negative: 2–4 units often in ED fridge. RhD− for females <50 yrs.
🧾 Type specific: Ready in ~15 min. ABO/Rh compatible but not cross-matched.
✅ Cross-matched: 30–40 min, safest.

🧾 Blood Product Notes

🟥 RBCs: Contain no clotting factors, fibrinogen or platelets. Risk of dilutional coagulopathy.
🧊 FFP: Replaces clotting factors. Needed after ~4U RBCs.
🟡 Cryoprecipitate: High fibrinogen content. Use when fibrinogen <1.5 g/L.
🧩 Platelets: Replace after significant loss/transfusion.
💊 Tranexamic acid: Antifibrinolytic. Give 1 g IV over 10 min then 1 g over 8 h. Improves survival in trauma bleeding (CRASH-2 trial).
🔥 Warm all fluids and blood before transfusion to avoid hypothermia.

🧃 Blood Products (Images)

Packed red cells

Platelets

Cryoprecipitate

📚 References

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Resuscitation - Acute Haemorrhage