🚑 Rapid transfer to a specialist trauma centre whenever possible.
🩸 Early coagulation monitoring & support → goal-directed resuscitation.
🔪 Damage-control surgery is prioritised in unstable patients; definitive surgery only when physiology allows.

Haemorrhage Control

🖐️ Direct pressure with simple dressings = first-line for most civilian bleeding.
🩺 Foley catheter tamponade – can be used for penetrating junctional injuries (neck, axilla, groin).
🦵 Tourniquet – if direct pressure fails in life-threatening limb haemorrhage.
🦴 Pelvic binder – apply early in suspected unstable pelvic fracture (esp. prehospital).
💊 Tranexamic Acid (TXA): give ASAP in major trauma with suspected bleeding; avoid >3h post-injury unless clear hyperfibrinolysis.

🌟 Key Exam Pearl: TXA within 3 hours of injury reduces mortality (CRASH-2 trial).

Tourniquets

💉 Indicated for uncontrolled arterial bleeding in mangled extremity injuries, amputations, penetrating/blast wounds.
🪖 Evidence mainly from military combat trauma; safe and effective.
🚫 Not for closed injuries or minor bleeding.
⏱️ Limit to < 2 hours ideally. Rare complications (nerve palsy, ischaemia) if prolonged.
✅ Survival of extremity reported even after 6h in combat series.

Pelvic Ring Binders

💀 Unstable pelvic fractures = highly lethal; cause massive retroperitoneal bleeding.
🦴 Early application of pelvic binder reduces pelvic volume & bleeding → used increasingly prehospital.
⚠️ Difficult to detect clinically (esp. unconscious patients) → maintain high suspicion.
📌 Further management:
- External fixation
- Retroperitoneal packing
- Angioembolisation
- Resuscitative Endovascular Balloon Occlusion of Aorta (REBOA)
Multidisciplinary team (trauma, ortho, interventional radiology) essential.

Anticoagulant Reversal

⏱️ Rapid reversal in actively bleeding trauma patients.
💉 Prothrombin Complex Concentrate (PCC) = first line for VKA reversal. Plasma is NOT recommended.
⚠️ Do NOT reverse if no bleeding present – seek haematology advice.
📊 Activate major haemorrhage protocol based on physiology & resuscitation response, not a static “risk score.”
💉 If IV access fails → intraosseous access is recommended prehospital.

Volume Resuscitation

📉 Restrictive strategy until bleeding controlled (avoid dislodging clots/dilutional coagulopathy).
🚑 Prehospital: titrate to palpable central pulse (carotid/femoral).
🏥 Hospital: move rapidly to definitive haemorrhage control; titrate to maintain central circulation.
🧠 With TBI:
- If haemorrhage dominates → restrictive fluids.
- If TBI dominates → maintain cerebral perfusion pressure (less restrictive).
💉 Crystalloids: avoid if blood available; use only as a bridge prehospital.
🩸 Balanced transfusion: Adults 1:1 RBC:Plasma; Children weight-based 1:1.

Damage Control Surgery

🚨 Unstable + non-responsive → damage control surgery (control bleeding/contamination, temporary closure).
📈 Unstable but responding → consider definitive surgery.
🟢 Stable physiology → proceed with definitive repair.

📝 Summary: - Stop bleeding early (pressure, tourniquet, binder, packing). - Reverse anticoagulants if bleeding. - Restrictive fluids until control achieved. - Early TXA (within 3h). - Escalate to damage-control surgery if instability persists.

References

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Trauma : NICE Guidance Haemorrhage

Main Principles