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.

References15ShowHide

1. [1]Shakur H, Roberts I, Bautista R, et al. Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo-controlled trial Lancet, 2010.PMID 20554319
2. [2]Holcomb JB, Tilley BC, Baraniuk S, et al. Transfusion of plasma, platelets, and red blood cells in a 1:1:1 vs a 1:1:2 ratio and mortality in patients with severe trauma: the PROPPR randomized clinical trial JAMA, 2015.PMID 25647203
3. [3]Rossaint R, Bouillon B, Cerny V, et al. The European guideline on management of major bleeding and coagulopathy following trauma: sixth edition Crit Care, 2023.PMID 36859355
4. [4]Roberts I, Shakur H, Afolabi A, et al. The importance of early treatment with tranexamic acid in bleeding trauma patients: an exploratory analysis of the CRASH-2 randomised controlled trial Lancet, 2011.PMID 21439633
5. [5]Morrison JJ, Dubose JJ, Rasmussen TE, et al. Military Application of Tranexamic Acid in Trauma Emergency Resuscitation (MATTERs) Study Arch Surg, 2012.PMID 22006852
6. [6]WOMAN Trial Collaborators Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with post-partum haemorrhage (WOMAN): an international, randomised, double-blind, placebo-controlled trial Lancet, 2017.PMID 28456509
7. [7]Baksaas-Aasen K, Gall LS, Stensballe J, et al. Viscoelastic haemostatic assay augmented protocols for major trauma haemorrhage (ITACTIC): a randomized, controlled trial Intensive Care Med, 2021.PMID 33048195
8. [8]Holcomb JB, del Junco DJ, Fox EE, et al. The prospective, observational, multicenter, major trauma transfusion (PROMMTT) study: comparative effectiveness of a time-varying treatment with competing risks JAMA Surg, 2013.PMID 23560283
9. [9]Gallos I, Devall A, Martin J, et al. Randomized Trial of Early Detection and Treatment of Postpartum Hemorrhage N Engl J Med, 2023.PMID 37158447
10. [10]Levy JH, Welsby I, Goodnough LT Fibrinogen as a therapeutic target for bleeding: a review of critical levels and replacement therapy Transfusion, 2014.PMID 24117955
11. [11]Callum J, Farkouh ME, Scales DC, et al. Effect of Fibrinogen Concentrate vs Cryoprecipitate on Blood Component Transfusion After Cardiac Surgery: The FIBRES Randomized Clinical Trial JAMA, 2019.PMID 31634905
12. [12]Jairath V, Kahan BC, Gray A, et al. Restrictive versus liberal blood transfusion for acute upper gastrointestinal bleeding (TRIGGER) Lancet, 2015.PMID 25956718
13. [13]Cascone AE, Daley MJ, Pan N, et al. Low-dose versus standard-dose four-factor prothrombin complex concentrate for factor-Xa inhibitor intracranial hemorrhage Pharmacotherapy, 2021.PMID 33866591
14. [14]Vidal J, DePalma R, Forouzan L Reversal of Dabigatran Bleeding and Coagulopathy Using Idarucizumab in a Patient With Acute Kidney Injury P T, 2018.PMID 30559587
15. [15]Widmer M, Piaggio G, Nguyen TMH, et al. Heat-Stable Carbetocin versus Oxytocin to Prevent Hemorrhage after Vaginal Birth N Engl J Med, 2018.PMID 29949473