Management of Massive Bleeding

Initial Actions

The American Society of Anesthesiologists recommends immediate control of obvious bleeding through direct pressure, tourniquets, or hemostatic dressings 1, 3
Administer high FiO2 and secure large-bore IV access (including central access if needed) to ensure adequate oxygenation and circulation 3
Obtain baseline laboratory tests, including FBC, PT, aPTT, Clauss fibrinogen, and cross-match, to guide further management 3
Initiate fluid resuscitation with warmed blood products (O negative initially if cross-matched blood unavailable) to prevent hypothermia and dilutional coagulopathy 1, 3

The American College of Surgeons recommends administering blood products in a 1:1:1 ratio of RBC:FFP:platelets for severely injured patients with massive bleeding 4
Begin with early FFP administration at 10-15 ml/kg to prevent dilutional coagulopathy, as recommended by the European Society of Anaesthesiology 5
Maintain a minimum platelet count of 75 × 10^9/L to prevent thrombocytopenia-related bleeding complications 1
For established coagulopathy (fibrinogen <1 g/L or PT/aPTT >1.5× normal), administer more than 15 ml/kg of FFP, as recommended by the American Society of Anesthesiologists 1, 6

Continuously assess for signs of ongoing bleeding (visible blood loss, hemodynamic instability) and perform early imaging (ultrasound, CT) or surgery as appropriate for definitive hemorrhage control 3
Consider cell salvage autotransfusion when appropriate to minimize blood loss and reduce the need for allogenic blood transfusion 3
Once bleeding is controlled, normalize blood pressure, acid-base status, and temperature to prevent further complications 3

Target fibrinogen levels >1 g/L using fibrinogen concentrate or cryoprecipitate to prevent coagulopathy-related bleeding complications 1, 6
For dilutional coagulopathy, administer FFP early in the resuscitation, as recommended by the European Society of Anaesthesiology 3, 7

Admit to critical care for ongoing monitoring and management to prevent further complications 3
Initiate standard venous thromboprophylaxis as soon as hemostasis is secured, as patients rapidly develop a prothrombotic state, as recommended by the American College of Chest Physicians 1, 3

Delaying activation of the massive transfusion protocol can increase mortality; activate early when massive hemorrhage is anticipated, as recommended by the American College of Surgeons 1, 8
Waiting for laboratory results before administering blood products in obvious massive hemorrhage increases mortality, as reported by the Critical Care Society 4

For trauma patients, damage control surgery may be necessary before complete physiologic normalization, as recommended by the American College of Surgeons 3
Monitor for and correct electrolyte abnormalities, particularly hypocalcemia from citrate toxicity, to prevent cardiac dysfunction, as recommended by the European Society of Anaesthesiology 5