Managing the Critical Bleeder!!

aka Hematology Hoodwinker 003

It’s 3am Monday morning when a 23 male is brought in with multiple small calibre gun shot wounds to his back and chest.

His current vital signs are:

  • Pulse: 127
  • BP: 78/32
  • Spo2 91 on 15 o2 via NRBM
  • RR 11
  • GCS 13/15 (E3, V4, M6)

You obtain a quick blood gas which shows the following:

  • pH 7.14
  • P02 74
  • PC02 52
  • HB 68
  • Lactate  7

What are your initial priorities in managing this case? Is it time to start the massive transfusion protocol?


Questions

Q1. What are the definitions used to define “Critical Bleeding” and “Massive Transfusion”?

Answer and interpretation

Critical Bleeding is defined as:

major haemorrhage that is life threatening and likely to result in the need for massive transfusion.

Broadly critical bleeding falls into 2 categories:

  1. Major haemorrhage that is life threatening and is likely to result in the need for massive transfusion
  2. Haemorrhage of a smaller volume in a critical area or organ (e.g. intracranial, intraspinal or intraoccular), resulting in patient morbidity or mortality

Massive Transfusion may be defined:

  • In adults, as a transfusion of half of one blood volume in 4 hours, or more than one blood volume in 24 hours (adult blood volume is approximately 70mL/kg)
  • In children, as a transfusion of more than 40mL blood/kg (blood volume of children older than neonates is approximately 80mL/kg).

Massive transfusion involves the administration of packed red blood cells, platelets and fresh frozen plasma on a 2.1.1 unit basis.

“Ultimately, the importance of defining critical bleeding or massive transfusion is to facilitate early recognition of this condition, or its potential, so that appropriate management can be instituted.”


Q2. What are the 5 common causes of critical bleeding?

Answer and interpretation
  1. Trauma
  2. Gastrointestinal bleeding
  3. Ruptured aortic aneurysm
  4. Obstetric haemorrhage
  5. Surgical procedures

Q3. What should be evaluated for in the initial assessment of the critically bleeding patient?

Answer and interpretation

Changes in physiological criteria can be important determinants in identifying critical bleeding, however avoid relying just on systolic blood pressure as a sole determinant of haemorraghic shock as this may result in a delayed recognition due to patients physiological compensating measures.

Initial assessment should include the evaluation of the following:

  • History
  • Systolic blood pressure
  • Heart rate
  • Pulse pressure
  • Peripheral perfusion
  • Mental status
  • Respiratory rate
  • Urine output
  • Haemoglobin and haemocrit
  • Coagulation status
  • Acid-base status
  • Temperature

Remember the patients physiological response will vary depending on the presence of the following:

  • Age
  • Cardiovascular disease (Hypertension, heart failure, pacemaker)
  • Medications (Beta-blockers, Calcium channel blockers, Digoxin)
  • Presence of hypothermia

Q4. What classification tool can assist you in classifying haemorrhagic shock in the critically bleeding adult patient?

Answer and interpretation

The American College of Surgeons have created a tool to help you classify stages of haemorrhagic shock.

In clinical reality, the classification is not very useful — unless you’re trying to pass an exam or an ATLS course…

Learn more at Resus.ME — Evidence refutes ATLS shock classification


Q5. What is permissive hypotension and minimal volume resuscitation?

Answer and interpretation

Past management practices for haemorrhagic shock involved aggressive fluid resuscitation with crystalloid solutions to achieve and maintain a near normal blood pressure. Unfortunately this lead to following complications occurring:

  • Oedema, compartment syndrome and acute lung injury
  • Exacerbation of anaemia, thrombocytopenia and coagulopathy due ti haemodilution
  • Exacerbation of bleeding due to possible clot disruption

Following research showing these complications the concept of permissive hypotension and minimal volume resuscitation was developed and dates back to being used during World War II in the resuscitation of victims of combat.

“Permissive hypotension and minimal volume resuscitation are strategies in which systolic blood pressures of 80-100 mm Hg are tolerated while bleeding is being controlled.”

Permission hypotension is generally employed in the management of ruptured abdominal aneurysms, however is contraindicated in the management of traumatic brain injury as it will reduced cerebral perfusion pressure and oxygenation further leading to secondary brain injury.


Q6. What is the concept behind damage control surgery?

Answer and interpretation

“Damage control surgery refers to the timely use if a staged approach in the treatment of the actively bleeding shocked patient.”

This approach emphasises control of bleeding and prevention of further contamination, to allow correction of hypothermia, coagulopathy and acidosis before definitive surgery is undertaken.

There are five critical decision-making stages in damage control surgery:

  1. Early patient selection
  2. Abbreviated life-saving surgery
  3. Secondary resuscitation
  4. Deferred resuscitation
  5. Reconstructive surgery, if required.

Damage control surgery works to help minimise/prevent the lethal triad:

Trauma’s Lethal Triad of Hypothermia, Acidosis & Coagulopathy
Trauma’s Lethal Triad of Hypothermia, Acidosis & Coagulopathy

Q7. Which biochemical values require monitoring in the critically bleeding patient?

Answer and interpretation

In patients with critical bleeding requiring massive transfusion, the following parameters should be measured early and frequently:

  • Temperature
  • Acid-base status
  • Ionised calcium
  • Haemoglobin
  • Platelet count
  • PT/INR
  • APTT
  • Fibrinogen level

Values trending towards normal will indicate successful management of the critically bleeding patient.

Values indicating critical physiological derangement include:

  • Temperature <35
  • pH <7.2, base excess >-6, lactate >4mmol/L
  • Ionised calcium <1.1mmol/L
  • Platelet count <50 x 10/L
  • PT > 1.5 X normal
  • INR >.1.5 X normal
  • Fibrinogen level <1.0g
  • APTT <1.0g/L

Q8. When should activation of the massive transfusion pack occur?

Answer and interpretation

The following flow charts can be used as a guide to assist you:

When to organise the massive transfusion pack:

Suggested criteria for activating the massive transfusion pack:


Q9. What effect does dose, timing and ratio of component therapy have on patient outcomes?

Answer and interpretation

Although the jury is still out on what is the optimum timing ratio for PRBC, FFP and Platelets, most studies have shown significant improved survival rates in patients receiving  2, 1,1, some studies and author’s recommend doing 1,1,1 in patients requiring massive transfusion. Further studies are needed before a recommended target ratio for PRBC, FFP, and platelets can be given.

Remember:

  • Blood component replacement should be guided by clinical assessment and results of coagulation tests.

Optimum management requires prompt action, as wells good communication and coordination between treating clinicians, diagnostic laboratories and the transfusion service providers.


Q10. What are the recommendations for using Tranexamic Acid in the critically bleeding patient?

Answer and interpretation

Although the guideline reviewers did not specifically address the effect of antifibrinolytic therapy in critically bleeding patients requiring massive transfusion. The reviewers felt it necessary to included the data from the recently published  CRASH2 Trial , that showed improved survival in trauma patients that received tranexamic acid.

What is Tranexamic Acid?

  • It is an antifibrinolytic that competitively inhibits the activation of plasminogen to plasmin, a molecule responsible for the degradation of fibrin.

When should I give Tranexamic Acid?

  • Tranexamic acid should be considered in patients with,or at risk of, significant haemorrhage.
  • The guideline reviewers make particular not to the fact that Tranexamic acid should be used as an adjunct in the critically bleeding patient, not as a ‘magic bullet”

What dose of Tranexamic Acid should i use?

  • Loading Does 1g over 10mins IV
  • Followed by infusion of 1g over 8 hours IV

Learn more about tranexamic acid:


References

Hematology Hoodwinker LITFL 700

CLINICAL CASES

Hematology Hoodwinker

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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