Management of Massive Blood Loss

Immediate Actions and Team Activation

The British Journal of Anaesthesia recommends immediately activating the hospital's major haemorrhage protocol, establishing large-bore IV access, and pursuing three priorities: restore circulating volume with warmed fluids, achieve surgical haemostasis, and correct coagulopathy with early fresh frozen plasma administration 1, 2
Designate a coordinator from permanent clinical staff to manage communication, documentation, and liaison between surgical, anaesthetic, haematology teams, blood bank, and laboratory services 1, 3
Activate the major haemorrhage protocol immediately when massive haemorrhage is declared—this mobilizes clinical, laboratory, and logistic responses simultaneously 2, 4
Apply direct pressure to any obvious bleeding source as the most effective initial medical intervention for haemorrhage control; use tourniquets or haemostatic dressings for extremity bleeding 2, 4

Insert two large-bore peripheral cannulae for rapid fluid administration 1, 3, 5
Infuse warmed crystalloid or colloid rapidly to restore circulating volume; hypothermia dramatically increases mortality from organ failure and DIC 1, 6
Use blood warmers when infusion rate exceeds 50 ml/kg/h in adults to prevent hypothermia 1, 5
Monitor central venous pressure and aim to maintain normal blood pressure with urine output >30 ml/h 1, 3

In extreme emergency, use un-crossmatched group O Rh-negative blood, limited to 2 units maximum 1, 5, 6
When blood group known, use un-crossmatched ABO group-specific blood; laboratory completes cross-match after issue 1, 5
After 1 blood volume replacement, further cross-matching not required 1, 5
Administer early FFP when a senior clinician anticipates massive haemorrhage, before coagulopathy develops 2, 4
Target PT and APTT <1.5 times control mean; fibrinogen <1 g/L or PT/APTT >1.5 times normal indicates established haemostatic failure predictive of microvascular bleeding 1, 2, 4
Allow 30 minutes for thawing time and coordinate early with blood centre as delivery may take up to 2 hours 1, 3
For massive transfusion, use 4:4:1 ratio of red blood cells:FFP:pooled platelets in severely traumatized patients requiring massive transfusion 2

Obtain baseline samples immediately: FBC, PT, APTT, fibrinogen, blood bank sample, biochemical profile, blood gases 1, 3, 5
Ensure correct sample identity—misidentification is the commonest transfusion risk 1, 3
Repeat coagulation studies every 4 hours or after 1/3 blood volume replacement; you may need to give components before results are available 1, 5, 6
Repeat testing after blood component infusion to guide ongoing therapy 1, 3

Pursue early surgical or obstetric intervention to arrest bleeding at the source 1, 3, 5
Consider interventional radiology for haemorrhage control when appropriate 1, 3
Employ intraoperative blood salvage if available and appropriate; contraindicated if wound is heavily contaminated 1, 6

Blood loss is frequently underestimated in clinical practice; haemoglobin and haematocrit do not fall for several hours after acute haemorrhage 1, 6, 7
Stable vital signs do not exclude significant blood loss—silent ischaemia may occur despite apparently stable haemodynamics 6, 7
Hypothermia, acidosis, and shock create a lethal triad leading to DIC with high mortality 1, 5
Loss of >40% blood volume is immediately life-threatening; red cell transfusion typically required when 30-40% blood volume is lost 1, 6, 7

Commence venous thromboprophylaxis as soon as haemostasis is secured, as patients develop a prothrombotic state following massive haemorrhage 2, 4