Massive haemorrhage may be defined as bleeding > 150ml/min or > 50% blood volume lost in < 3 hours. Where blood loss is difficult to estimate, use of clinical symptoms & signs (sweating, thirst, restlessness, pallor, tachycardia & fall in BP) may be more reliable (Stanworth et al, 2022) recommend HR>110, BP<90. For patients on anticoagulant medication suffering life, limb or sight-threatening bleeding, details for anticoagulant reversal can be found in the reversal of oral anticoagulation guidelines.

Call Switchboard on 2222 & state ‘Massive haemorrhage on (relevant ward/department) and the site (FPH or WPH or HWH).

Switchboard will alert the appropriate senior members of staff. This group of professionals can vary depending on local practise but as a minimum will alert

• Transfusion Laboratory (All sites)

• Porters (HWPH)

• On call senior Anaesthetist (who is required to attend at FPH)

Contact now needs to be made with Transfusion Laboratory who cannot proceed until they have the patient demographics (full name, date of birth & unique identifying number) so that they can start checking for samples, blood already issued etc. Transfusion Laboratory or the CCL can initiate this contact.

NB: if you need further personnel or teams to manage the patient this should be communicated via switchboard, in the most appropriate way.

Release of blood components/products is not dependent on the approval of a Consultant Haematologist although they can be contacted for advice at any point.

One of the most significant factors for ensuring blood components/products are ready as soon as possible is effective, timely, communication with Transfusion Laboratory. This should be achieved by assigning a Clinical Communication Lead (CCL)

The language you use is pivotal to how your requests will be interpreted i.e. if you ask for ‘cross matched blood’ this is generally not immediately available; if you ask for ‘blood’ & state how quickly you need it the Transfusion Laboratory staff will advise you of the options & how long each option takes.

Clinical Communication Lead (CCL)

Who: Senior registered professional, who can fully understand & communicate the clinical situation, requirements & progress.

CCL role: Critical role in communicating patient’s transfusion needs to Transfusion Laboratory

• Ring Transfusion Laboratory asap

• Tell them ‘I am the communication lead for the massive haemorrhage on – location –‘

• Give them patient identity & clinical details

• Advise whether the bleeding is controlled or uncontrolled

• Give them your details & contact numbers/bleeps

• Inform them of any emergency/flying squad blood taken

• Inform Transfusion Laboratory when initial components have been used & whether further blood components are required (see flow chart)

• Maintain frequent / regular contact with Transfusion Laboratory re availability of blood / blood results

• Liaise with Team Leader re transfusion requirements

• Send staff to collect blood / blood components

• Ensure sample taker is aware of samples required & samples taken meet all criteria*

• Liaise with Consultant Haematologist if expert advice required**

• If patient moves / bleeding resolves / patient dies

• Tell Transfusion Laboratory

• Hand role over if patient moves / as appropriate

* It is acknowledged that obtaining samples in massive haemorrhage situations can be very difficult. A lack of sample(s) should never delay provision of blood in a life threatening massive haemorrhage as emergency blood is available in several locations However cross matched blood is the ideal, so Transfusion Laboratory will ask for a sample & will notify the clinical area of the requirement for a second group check if applicable. Please communicate clearly with Transfusion Laboratory if samples are not possible at this stage.

**You do not need the approval of a Consultant Haematologist for release of blood products once the major haemorrhage protocol has been activated, with the exception of Novo7.

Clinical areas may also assign a team leader who is responsible for managing the team and assigning duties as follows:

• Sample Taker / Documenter who ensure urgent cross match samples are taken and sent to the laboratory as per policy and document blood being used.

• Transporter who is responsible for delivery of urgent samples to the lab and collection and transport of blood components to and from the laboratory as per policy.

4.1 Red cells

If blood is needed immediately, with no time for compatibility testing, emergency O Red cells is available. See appendix 1 for location

• O RhD Negative blood is available in pink bags for patients <50 years (with childbearing potential) & children under 18 years of age

• O RhD Positive blood is available in blue bags for patients ≥50 years (beyond childbearing potential) and male patients over 18 years of age

• Group specific uncrossmatched blood may be available

• Fully cross matched blood will be supplied as soon as possible (~ 60 minutes from receipt of sample)

Two units of Emergency blood can be removed at the same time.

Issue of blood components

Analysis of massive haemorrhage (MH) calls indicate that the majority of MH calls are for controlled blood loss which clinicians often manage with red cells only. The MH protocol has therefore been redesigned to have options for controlled blood loss & uncontrolled blood loss.

The Clinical Communication Lead can state ‘controlled’ (lab will issue 4 red cells) or ‘uncontrolled’ (lab will issue 4 red cells, 4 FFP, 1 pool of platelets) at any stage or request other components / products as clinically indicated.

Controlled blood loss does not require a 1-1 RC to FFP ratio; this only applies in uncontrolled blood loss or trauma cases.

Once the first & second requests for components have been used, further blood products have to be guided by the individual patient’s clinical situation (site of bleeding, aetiology, interventions planned).

4.2 Platelets

• 1 pool of platelets will be in stock for the purpose of the massive haemorrhage protocol.

• Once used the platelets will be restocked; however delivery of stock comes from NHSBT (London/Oxford) so will not be immediate.

• In the event of a second Massive Haemorrhage happening shortly after or simultaneously then other components will be issued WITHOUT platelets. In such an unlikely event further platelets will be ordered from the NHSBT transfusion centre on a blue-light request and if available transferred from another site within the network.

4.3 Fresh Frozen Plasma

FFP is a frozen component and will take approximately 30 minutes to defrost.

Across Frimley Health there is a trial to use pre-thawed plasma which is available from the main issue fridge in the transfusion laboratory. Two units of pre thawed plasma is available as emergency stock, whilst additional units are defrosted.

4.4 Novoseven (rVIIa): recombinant Factor 7

Novoseven can be of clinical value in some patients but use should be discussed with the Consultant haematologist. If the Consultant haematologist is not available, a Consultant anaesthetist can authorise the use of Novoseven. In order for Novoseven to be effective fibrinogen levels and platelets should be optimised prior to administration of rVIIa

5.1 Life / Limb Threatening Haemorrhage In Patients On Anticoagulants

Idarucizumab (for reversing dabigatran), andexanet alfa (for reversing Xa inhibitors) and beriplex (for reversing warfarin or Xa inhibitors) are available and should be used as per trust guidance on reversal of oral anti-coagulants. Consultant Haematologist approval for issue of Beriplex in these situations is NOT required.

5.2 Obstetric

In major obstetric haemorrhage, blood component management should follow a similar pathway as for non-pregnant patients, except that meticulous attention should be paid to fibrinogen levels & consideration given to the early use of fibrinogen supplementation when fibrinogen levels are <2·0 g/l & there is on-going bleeding. Tranexamic acid (1 g intravenously) is recommended for women with post-partum haemorrhage within 3 h of bleed onset. If bleeding continues after 30 min, or it stopped and restarted within 24 h of the first TXA dose, a second dose of 1 g should be given (as per the schedule of the WOMAN trial).

5.3 Trauma

Adult trauma patients with, or at risk of major haemorrhage, should be given Tranexamic acid as soon as possible after injury.

Spire Clare Park Hospital, Spire Thames Valley Hospital & Heatherwood Hospital

Due to the geographical distance between these Hospitals & FPH/WPH Transfusion Laboratories it is not possible to optimally manage a massive haemorrhage at these sites. The required actions are therefore to:

• Identify that a patient is having a massive haemorrhage

• Alert the emergency ambulance service by dialling 999

• Resuscitate the patient; transfuse emergency group O blood if required.

• Request additional components as required, or the laboratory will issues components as per MH protocol.

• Transfer the patient when feasible

• Alert the receiving hospital by asking switchboard to activate the massive haemorrhage protocol & inform the receiving department (ED, Theatres/ICU)

Topic: Massive haemorrhage
Sources checked: Medline, Embase, Cochrane Library, TRIP database, NICE, BMJ Best Practice, UpToDate
Search terms: (massive or major) and (haemorrhage or hemorrhage)
Limits: Published since 2018

Guidelines

Stanworth, S.J. et al. (2022) 'Haematological management of major haemorrhage: a British Society for Haematology guideline', British Journal of Haematology, 198(4), pp. 654-667. Available at: https://onlinelibrary.wiley.com/doi/10.1111/bjh.18275 (Accessed: 18 September 2023).

Curry, N.S. et al. (2018) ‘The use of viscoelastic haemostatic assays in the management of major bleeding: a British Society for Haematology guideline’, British Journal of Haematology, 182(6), pp. 789-806. Available at: https://onlinelibrary.wiley.com/doi/full/10.1111/bjh.15524 (Accessed: 18 September 2023).

Joint United Kingdom (UK) Blood Transfusion and Tissue Transplantation Services Professional Advisory Committee [JPAC] (2023) Transfusion management of major haemorrhage. Available at: https://www.transfusionguidelines.org/transfusion-handbook/7-effective-transfusion-in-surgery-and-critical-care/7-3-transfusion-management-of-major-haemorrhage (Accessed: 18 September 2023).

Llau, J.V. et al. (2023) ‘Multidisciplinary consensus document on the management of massive haemorrhage. First update 2023 (document HEMOMAS-II)’, Medicina Intensiva, 47(8), pp. 454-467. https://doi.org/10.1016/j.medine.2023.03.019

Robinson, D. et al. (2022) ‘Guideline No. 431: Postpartum hemorrhage and hemorrhagic shock’, Journal of Obstetrics and Gynaecology Canada, 44(12), pp. 1293-1310.e1. https://doi.org/10.1016/j.jogc.2022.10.002

Spahn, D.R. et al. (2019) ‘The European guideline on management of major bleeding and coagulopathy following trauma: fifth edition’,Critical care (London, England),23 (1), 98. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6436241/(Accessed: 18 September 2023).

Reports / Summaries

Belfort, M.A. (2023) ‘Overview of postpartum hemorrhage’, in T.W. Post (ed)UpToDate. Waltham, MA: UpToDate. Available at: https://www.uptodate.com/contents/overview-of-postpartum-hemorrhage?csi=16565cd6-6d24-4280-ae62-de724cac6773&#x26;source=contentShare (Accessed: 18 September 2023).

Colwell, C. (2023) ‘Initial management of moderate to severe hemorrhage in the adult trauma patient’, in T.W. Post (ed) UpToDate. Waltham, MA: UpToDate. Available at:https://www.uptodate.com/contents/initial-management-of-moderate-to-severe-hemorrhage-in-the-adult-trauma-patient?csi=c8f3fba2-505b-46ef-be1e-9665842862ef&#x26;source=contentShare (Accessed: 18 September 2023).

Hess, J.R. (2023) ‘Massive blood transfusion’, in T.W. Post (ed) UpToDate. Waltham, MA: UpToDate. Available at:https://www.uptodate.com/contents/massive-blood-transfusion?csi=18965663-44f6-4d61-a13d-b6d665f406c4&#x26;source=contentShare (Accessed: 18 September 2023).

Moise Jr, K.J. (2022) ‘Spontaneous massive fetomaternal hemorrhage’, in T.W. Post (ed) UpToDate. Waltham, MA: UpToDate. Available at: https://www.uptodate.com/contents/spontaneous-massive-fetomaternal-hemorrhage?csi=e9a4f0bb-1702-49fc-8986-39cdd946191c&#x26;source=contentShare (Accessed: 18 September 2023).

[NB. These are time-limited URLs to the full-text. If adding an UpToDate reference to a guideline, usehttps://www.uptodate.com/

Reviews

Avery, P. et al. (2020) ‘Whole blood transfusion versus component therapy in adult trauma patients with acute major haemorrhage’, Emergency Medicine Journal, 37(6), pp. 370-378. https://dx.doi.org/10.1136/emermed-2019-209040

Bialkower, M., Garnier, G. (2022) ‘Fibrinogen diagnostics in major hemorrhage’, Critical Reviews in Analytical Chemistry, 52(1), pp. 194-209. https://dx.doi.org/10.1080/10408347.2020.1793098

Curry, N. S., Davenport, R. (2019) ‘Transfusion strategies for major haemorrhage in trauma’, British Journal of Haematology, 184(4), pp. 508-523. Available at: https: onlinelibrary.wiley.com="" doi="" 10.1111="" bjh.15737="" (Accessed: 18 September 2023).

Feuerstein, S.J. et al. (2020) ‘Freeze-dried plasma in major haemorrhage: a systematic review’, Vox Sanguinis, 115(4), pp. 263-274. Available at: https://onlinelibrary.wiley.com/doi/10.1111/bjh.15737 (Accessed: 18 September 2023).

Karlsson, O. (2022) ‘Protocol for postpartum haemorrhage including massive transfusion’, Best Practice & Research Clinical Anaesthesiology, 36(3-4), pp. 427-432. https://dx.doi.org/10.1016/j.bpa.2022.09.003

Massoth, C. et al. (2023) ‘Coagulation management and transfusion in massive postpartum hemorrhage’, Current Opinion in Anaesthesiology, 36(3), pp. 281-287. https://dx.doi.org/10.1097/ACO.0000000000001258

Park, H.S., Cho, H.S. (2020) ‘Management of massive hemorrhage in pregnant women with placenta previa’, Anesthesia & Pain Medicine, 15(4), pp. 409-416. Available at: https://anesth-pain-med.org/journal/view.php?doi=10.17085/apm.20076 (Accessed: 18 September 2023).

Petrosoniak, A. et al. (2023) ‘Massive hemorrhage protocol: a practical approach to the bleeding trauma patient’, Emergency Medicine Clinics of North America, 41(1), pp. 51-69. https://dx.doi.org/10.1016/j.emc.2022.09.010

Ritchie, D.T. et al. (2020) ‘Empirical transfusion strategies for major hemorrhage in trauma patients: a systematic review’, The Journal of Trauma and Acute Care Surgery, 88(6), pp. 855-865. https://dx.doi.org/10.1097/TA.0000000000002685

Stallwood-Hall, C., Anderson, J., Ebeid, A. (2022) ‘Systematic review and meta-analysis of arterial embolization compared with traditional management on outcomes of traumatic massive facial haemorrhage’, ANZ Journal of Surgery, 92(5), pp. 988-993. https://dx.doi.org/10.1111/ans.17448

This guideline has been registered with the trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt contact a senior colleague or expert. Caution is advised when using guidelines after the review date. This guideline is for use in Frimley Health Trust hospitals only. Any use outside this location will not be supported by the Trust and will be at the risk of the individual using it.

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