Massive haemorrhage and transfusion

Massive haemorrhage is the loss of one blood volume or more within twenty-four hours, or half the blood volume within three hours, or a rate of blood loss above 150 millilitres per minute — any of which will kill the patient within minutes unless the bleeding is controlled and the circulation resuscitated with blood products. The emergency management of massive haemorrhage is built on a single principle: damage-control resuscitation, in which the resuscitation and the control of the bleeding run in parallel, the resuscitation uses blood products rather than crystalloid, and the lethal triad of hypothermia, acidosis and coagulopathy is actively prevented. The massive transfusion protocol is the operational tool that delivers the products rapidly and in the right ratio. [1]

The lethal triad

The lethal triad — hypothermia, acidosis and coagulopathy — is the self-perpetuating cycle that kills the massively bleeding patient, and its prevention is the rationale for every element of damage-control resuscitation.[3] The hypothermia impairs the coagulation cascade and the platelet function (the enzymes of coagulation are temperature-dependent). The acidosis (from the poor perfusion and the shock) further inhibits the coagulation enzymes and depresses the cardiac function. The coagulopathy — from the consumption, the dilution by crystalloid, and the dysfunction of the cold, acidotic platelets and enzymes — worsens the bleeding, which worsens the shock, the acidosis and the hypothermia. The triad is prevented by warming the patient, the fluids and the blood; by giving blood products rather than crystalloid; by correcting the acidosis through the restoration of perfusion; and by giving the coagulation factors and the platelets proactively through the protocol.

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