Makindo Medical Notes

Related Subjects: |Acute Haemorrhage |Initial Trauma Assessment and Management |Thoracic Trauma Assessment and Management |Flail Chest Rib fractures |Resuscitative Thoracotomy |Haemorrhage control |Traumatic Head/Brain Injury |Traumatic Cardiac Arrest |Abdominal trauma |Tranexamic Acid |Silver Trauma

💉 "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.

📖 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

• University of Glasgow – Trauma Guide
• UK Transfusion Guidelines