Major haemorrhage protocol: Argyll & Bute HSCP (Guidelines)

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It is imperative that all members of the clinical team are aware of their roles. These should be allocated as soon as possible by the team leader.

• Team Leader: allocates roles and determines patient management.
• Communication Lead: allocated to communicating with laboratories/theatres, other staff as required and remote specialist services such as haematology, EMRS, Scotstar and paediatrics.
• Resuscitation: ‘ABC’, vascular access, blood component administration etc.
• Haemorrhage control: directly attempting to stem blood loss via local measures.
• Responsibility for samples: ensure samples are taken correctly, labelled, forms completed and transported to lab quickly.
• Documentation: to ensure all events during episode are documented, to ensure blood component, fluid and drug administration recorded on correct paperwork, to document vital signs throughout and to ensure ‘traceability’ returns complete.

• Phone 2222 and say “Major Haemorrhage Event”
• State:
  • Location of patient hospital
  • Clinical area
  • Clinician’s name and contact details.
    

Note: this only alerts individuals relating to major haemorrhage it does NOT activate the resuscitation team.

Information required by blood bank 

It is vital that the laboratory have all relevant clinical details so that they can respond both to the immediate need for blood products and plan for what is likely to be needed subsequently.

Patient details:

• Identified patient: forename, surname, DOB, gender PLUS CHI number or (for patients without a CHI) a unique TH identifying number.
• Unidentified patient: gender, unique TH identifying number.

Communication pathways:

• Location and contact number of ward or area.
• Contact details for communication lead.

Relevant clinical details:

• Urgency of the situation and the clinical condition of the patient.
• Cause of haemorrhage, eg, trauma, GI bleed, relevant background clinical details such as known coagulopathy or liver disease, anticoagulant use.
• Any immediate plans to control haemorrhage such as surgery, endoscopy or radiology.
• Whether transfer of the patient is being considered.
• NB the laboratory should be updated as and when more information becomes available. 

Number and nature of components required:

• This should be considered in the light of the clinical circumstances.
• Bear in mind that 4 units of uncross-matched O-ve blood is available for immediate use prior to any lab requests.
• There is no absolute rule as to the amount of blood that should be requested, though for an uncontrolled major haemorrhage an initial request of 4 units of red blood cells and 4 units of FFP is a reasonable starting point. 

In coagulopathic patients platelets should be requested early to allow transport, which will take at least 2 hours. Confirm which samples have been sent or may be needed.

• See below for details of tests to be sent.
• Assume that written request forms will be required and confirm this with the BMS.
• Note: the requirement, wherever possible, is for two samples for cross-match to be taken by two different clinicians in separate venepuncture episodes, unless there is a recent group and save or cross-match on the system. Consider this when intravenous access is being planned. Most MH patients will require more than one wide bore IV cannula and, if samples can be taken at the time of each cannulation, this may provide suitable samples without requiring extra venepuncture procedures.

Time frame

Factor in time for samples to reach labs and for components to be delivered from Lab.

Between the hours of 9am and 5pm the laboratory delivers a full service, with an out-of-hours service provided outwith these times. Out-of-hours, time must be allowed for the BMS to travel into the hospital (up to 30 mins).

See table below for the time taken for different blood products to reach the patient and factor this into the management plan.

Emergency O-ve blood availability:

Blood component availability:

Control bleeding: 

• Local measures including pressure, tourniquets, and specialist dressings.
• Tranexamic acid (see below).
• Request senior surgical advice.
• Consider interventional radiology if available.

Resuscitation:

• Give O₂
• Insert two wide-bore cannulae (and take bloods).
• Apply non-invasive monitors.
• Controlled hypotension may be tolerated until red cells can be given (if not tolerated consider warmed crystalloid).
• Restore circulating volume with warm blood and plasma as soon as possible.
• Use Rapid Infuser, if available.
• Keep patient warm with forced hot air blanket.
• Place urinary catheter and urometer. Keep >0.5 mL/kg.
• Consider invasive monitoring, if available.
• Don’t forget IV analgesia if patient is in pain.

Request laboratory investigations:

Cross-match:

• Two samples are required, taken from two separate venepunctures (see above) unless there is a recent group & save on the system. If it is not possible to provide a second sample then this should be communicated to the laboratory.
• Only O-ve blood will be provided without a second sample.
  A second sample taken after transfusion with emergency O-ve blood will provide some limited information but will still be welcomed by the laboratory, as long as the timing is accurate and it is made clear that this is a post-transfusion sample.
• It is vital that clinicians communicate openly and honestly with the lab about the nature and timings of samples for cross match.

FBC, coagulation screen, fibrinogen, U+Es including calcium

• Use near patient testing if lab not immediately available.
• Ensure samples are sent to the lab.
• Do NOT solely rely on point of care testing for haemoglobin estimation.

Blood gases

• Use point of care testing.

Repeat samples after transfusion and at regular intervals (30 to 60mins)

• In particular note changes in haemoglobin, coagulation and fibrinogen, all of which will be used to guide onward management.

Blood component support

• Give packed red cells to maintain Hb 70 to 90g/L (>80g/L may be used in patients with co-morbidities):
• Consider urgency and whether uncrossed matched O-ve is required immediately, or wait for crossed-matched blood. (50 mins from time samples reach lab). 
  
  • Note: at the time of writing the LIH laboratory does NOT issue ABO group specific blood.
  • 4 units O-ve blood are available in LIH theatre fridge.
• Request an appropriate number of cross-matched units if a further requirement is anticipated.
  • Eg: one unit of blood will raise the Hb of a 70kg adult by approximately 10g/L once the source of the haemorrhage has been controlled.
  • Clinical judgement must be exercised in estimating the likely requirement, but if the requesting team are unsure, 4 units (plus 2 to 4 units of FFP) is a reasonable starting point.
• Use FBC and coagulation tests after component administration and at regular intervals to guide therapy (30 to 60 minutes)
• Where the patient has known antibodies or special requirements, discuss with haematology as soon as possible to agree on suitable components to prevent undue delay in transfusion.

Maintain platelet count >50 x 10⁹/L:

• Platelets are NOT automatically issued following a MH. The need for platelets should be considered in the light of the clinical circumstances, bearing in mind that there will be a delay of at least two hours once the request has been made.
  • 50 x 10⁹/L is generally accepted as the haemostatic level.
  • Discuss with the senior clinician and the on call haematologist and given the delay in transport, consider requesting if platelets falls below 75 x 10⁹/L.
• Anticipate that platelets will be <50 after 2 x blood volume replacements (8 to 12 units blood).
• Where CNS bleeding is suspected, maintain target platelet count >100 x 10⁹/L.

Maintain PT and APTT <1.5 x normal:

• Transfusion of large volumes fluids causes dilutional coagulopathy. In trauma there is also an increased tendency to acute coagulopathy and early DIC. Coagulopathy is further impaired by hypothermia, acidosis and reduced ionised Ca 2+. All adult major haemorrhage patients should have 4 units of FFP.
• In major trauma give 1:1 blood to FFP ratio.
• NOTE: if 4 units of emergency O negative blood have been given in a trauma patient, there will be an immediate requirement for 4 units of FFP from the lab in advance of more RBC.
• Anticipate that massive transfusion will result in increasing coagulopathy and discuss onward management with the on-call haematologist and the lab.
• Allow 30 mins thawing time for FFP.
  

Maintain Fibrinogen >1.5g/dL: 

• If fibrinogen <1g/dL despite FFP, discuss need for cryoprecipitate with on-call haematologist (normal adult dose: 2 pooled doses).
• Allow 30 mins thawing time for cryoprecipitate.
• If there is ongoing bleeding after the initial transfusion of blood products, two pools of cryoprecipitate should be considered and discussed with the on-call haematologist.
• NOTE: the threshold for cryoprecipitate transfusion in obstetric haemorrhage is higher and should be considered when fibrinogen is <2g/dL.

Tranexamic acid

The CRASH-2 trial in 2010 demonstrated that early (within 3 hours of injury) administration of Tranexamic acid improved the survival of patients with traumatic major haemorrhage. Evidence is now emerging of benefit for other causes of major haemorrhage, including obstetric haemorrhage (WOMAN Trial (Lancet May 2017, 389: 2105-2116) The exception being acute haemorrhage secondary to a gastro-intestinal cause (The HALT-IT Trial Collaborators, Lancet 2020; 395: 1927–36)

• Initial dose given within 3 hours of trauma: 1g IV over 10 minutes, followed by infusion of 1g over 8 hours
• Do NOT give tranexamic acid in established DIC.
• Do NOT give tranexamic acid in gastrointestinal bleeding.

Management of warfarinised patients:

• Seek senior clinical and haematology advice.
• Give vitamin K 2.5 to 10mg IV.
• Beriplex (Human prothrombin complex concentrate, PCC) is kept in A&E. Due to its high cost only a small amount is held. If it is used pharmacy must be informed as soon as possible so more can be ordered.

Beriplex should be given according to the table below:

NOTE: The use of desmopressin, rVIIa or aprotinin are no longer recommended in the management of major haemorrhage, unless as part of a clinical trial.

Management of patients on direct oral anticoagulants (DOACs)

Seek senior clinical and haematological advice.

Rivaroxaban or Apixaban (Inhibits Factor Xa)

• Reversal with andexanet alfa (Ondexxya).
• Should only be given following haematological advice.
• This is a very high cost medication. 
• A small stock is kept in A&E (Ward B).
• Pharmacy must be informed as soon as possible if this is used so that it can be reordered.

Dabigatran (inhibits factor IIa).

• Reversal with idarucizumab (Praxbind)
• No stock of this is kept in LIH.
• It can be transported urgently from Glasgow if recommended by the on-call haematologist.

Edoxaban (Inhibits Factor Xa).

• No specific antagonist exists.

Management of patients on heparin

• Stop heparin infusion.
• Consider protamine, a cationic peptide that will bind unfractionated heparin completely.
• Protamine will partially bind LMWH.
• Seek senior clinical or haematological advice on dosage and administration.

• Seek surgical input at an early stage as definitive management is likely to require urgent endoscopy
• NOTE: tranexamic acid is NOT recommended for use in gastrointestinal haemorrhage.
• Teripressin Acetate can be considered in known bleeding oesophageal varices in adults.
  • 1 to 2mg should be given by slow IV injection
  • A further 1mg can be given every 4 to 6 hours

The following complications should be anticipated and managed appropriately in patients receiving multiple units of blood components:

Blood component support

• Access nearest available group O-ve units.
• Give 20mL/kg red blood cells, when available, and tailor to Hb and ongoing blood loss.
• Give 20mL/kg FFP. This does NOT require coagulation screen results.
• Once blood results available, tailor blood component support to maintain: Hb >70g/L.
• If PT and APTT ratios >1.5: transfuse further 20mL/kg.
• If fibrinogen <0.8g/L: transfuse 5mL/kg of cryoprecipitate.
• If platelets <50 x 10⁹/L: transfuse 10mL/kg of platelets (20mL/kg if <30 x 10⁹/L).
  Note: NOT kept on site, so will take at least 2 hours to arrive. Discuss logistics with haematology and retrieval team.

Pharmacological interventions

Tranexamic acid

Should be given to trauma patients up to 3 hours after injury:

• 15mg/kg infused over 15 minutes followed by:
• 2mg/kg infusion for at least 8 hours or until bleeding stops.

Management of warfarinised patients

• Stop warfarin.
• Give vitamin K (30 microgram/kg IV), consider higher doses if INR >8.
• When there is active bleeding, clotting factor replacement is recommended as it gives superior clotting factor replacement compared to FFP. (PCC / trade name ‘Beriplex’).
• Dosage of Beriplex is calculated based on the current INR and patient’s weight:

• Repeat INR following administration of Beriplex.
• Further doses of Beriplex or vitamin K may be required.

Specialist advice and assistance

• Specialist advice on management of critically ill children should always be sought at an early stage from the on call paediatric team at RHSC Glasgow.
• The Scotstar paediatric retrieval team are very likely to be involved and should be contacted promptly as well as transferring the patient, they will offer on-site management, if required: 03333 990 222

• Contact EMRS via the usual Scotstar number: 03333 990 222.
• EMRS routinely carry 3 units emergency O-ve blood
• Use simple measures to control haemorrhage such as pelvic splint or direct pressure
• Package patient using vacuum mattress
• Avoid unnecessary patient movement (ie. log roll)
• Hypotensive resuscitation:
  • Aim for 70 to 80 mmHg systolic BP in penetrating trauma and 90mmHg in blunt trauma
  • Avoid crystalloids, colloids and vasporessors.
• Use blood components, if available locally.
• Use tranexamic acid for trauma, if available locally.

Administration of tranexamic acid

Any patient presenting within 3 hours of injury should be given tranexamic acid as per information above.

This is the responsibility of the clinical lead / haemorrhage coordinator.

• All paperwork should be completed including the traceability forms, which should be returned to the lab.
• Once the patient is stable, thromboprophylaxis should be considered and discussed with senior clinical team.
• Advice can also be sought from the on-call haematologist.

Audit

Activation of the major haemorrhage response should be audited by the local Hospital Transfusion Committee so that defects in the process can be identified, rectified, and lessons learned fed back to all staff involved in the major haemorrhage response.

1. The Association of Anaesthetists – Blood Transfusion and the Anaesthetist – Management of massive haemorrhage (this is a draft document, currently out for consultation).
2. Management of bleeding following major trauma: an updated European guideline Rossaint R. et al Critical Care 2010, 14: R52.
3. A practical guideline for the haematological management of major haemorrhage; Beverley J Hunt et al; British Journal of haematology (Sept 2015), Vol 170 Issue 6, Pg788 – 803.
4. Handbook of transfusion medicine
5. https://www.transfusionguidelines.org/red-book
6. Royal Hospital for Sick Children Major Haemorrhage Protocol. NHS Greater Glasgow and Clyde.

• ABG: Arterial blood gas
• A&E: Accident and Emergency
• APTT: Activated partial thromboplastin time
• BMS: Biomedical Scientist
• BP: Blood pressure
• Ca: Calcium
• CHI: Community health index
• CNS: Central nervous system
• Coag: coagulation
• DIC: Disseminated Intravascular Coagulation
• DOB: Date of birth
• Dept: Department
• DOAC: Direct oral anticoagulant
• ECG: Electrocardiogram
• EMRS: Emergency Medical Retrieval Service
• FBC: Full blood count
• FFP: Fresh frozen plasma
• GI: gastro intestinal
• Hb: Haemoglobin
• HR: Heart rate
• INR: International normalised ratio
• IV: Intravenous
• LMWH: Low molecular weight heparin
• MACHICC: Mid Argyll Community Hospital And Integrated Care Centre
• MH: Major Haemorrhage
• MHP: Major Haemorrhage Protocol
• LIH: Lorn and Isles Hospital, Oban
• NPT: Near patient testing
• O₂: Oxygen
• Obs: Observations
• PT: Partial thromboplastin 
• RBS: Red blood cells
• RR: Respiratory rate
• SaO₂: Oxygen saturation
• TH number: Temporary Health number
• U&E: Urea and electrolytes
• X-matched: cross-matched