Massive Hemorrhage

at the bedside

airway, breathing, circulation; high-flow oxygen, cardiac monitor; two large-bore cannulas (14–16 G), intraosseous if no access
press on it → direct pressure, tourniquet, position; the source decides who you call (endoscopy, surgery, interventional radiology, obstetrics)
call → blood bank, the team, ICU; group and crossmatch, CBC, PT/INR, APTT, fibrinogen, RFT, calcium, VBG with lactate
permissive hypotension → SBP 80–90 mmHg or a radial pulse until the source is controlled; higher if head injury
keep the patient warm

escalate now if: activate the massive transfusion protocol

bleeding with shock, or a blood volume in 24 h, or half a blood volume in 3 h → activate; do not wait for the crossmatch or the hemoglobin
on an anticoagulant → reverse now
trauma or obstetric bleeding within 3 h → tranexamic acid
shock persisting after products → advanced: shock, vasopressors

where is it coming from

GI → hematemesis, melena, hematochezia → GI bleed
surgical site or drain → back to theatre
retroperitoneal → anticoagulated, flank or back pain, falling hemoglobin with no visible blood; CT
ruptured AAA, ruptured ectopic → abdominal pain
obstetric, hemoptysis, epistaxis, trauma → obstetrics, respiratory (hemoptysis) or ENT (epistaxis), surgery

bleeding → source, onset, estimated loss, what has already been given
drug chart → anticoagulant (which, last dose), antiplatelet, recent heparin
history → liver disease, coagulopathy, recent surgery or procedure, previous transfusion reactions
shock → tachycardia, hypotension, confusion, cool peripheries, slow capillary refill; young patients compensate until they do not

group and crossmatch → first; O-negative or group-specific while waiting
CBC, PT/INR, APTT, fibrinogen → the baseline, then every 30–60 min while bleeding
ionized calcium, K⁺, VBG with lactate → citrate lowers calcium, stored blood raises potassium, lactate tracks perfusion
imaging → only once stable enough, CT angiography for an unseen source

control the source → pressure, tourniquet; endoscopy, interventional radiology or surgery called now
transfuse → red cells early, do not wait for the hemoglobin; red cells : plasma : platelets about 1 : 1 : 1
- platelets > 50 ×10⁹/L, > 100 in intracranial bleeding
- fibrinogen > 1.5 g/L with cryoprecipitate, > 2 in obstetric bleeding
- plasma for coagulopathy while bleeding; minimise crystalloid, blood is the fluid
adjuncts → trauma or obstetric bleeding: tranexamic acid 1 g IV over 10 min then 1 g over 8 h, within 3 h; not for GI bleeding (HALT-IT); calcium chloride or gluconate to keep ionized calcium > 1.1 mmol/L
reverse the anticoagulant → warfarin: 4F-PCC 25–50 IU/kg IV + vitamin K 10 mg IV; dabigatran: idarucizumab 5 g IV; apixaban or rivaroxaban: 4F-PCC with hematology; heparin: protamine → coagulation profile
break the lethal triad → warm the patient and the fluids, correct acidosis by perfusion, correct coagulopathy by products; watch K⁺, calcium and for TACO or TRALI → transfusion reaction
reassess → hemoglobin, platelets, fibrinogen, calcium, lactate every 30–60 min; stand the protocol down when bleeding is controlled and tell the lab

shock persists → advanced: shock, vasopressors & inotropes
hand over → products given, hemoglobin and coagulation trend, source control plan, protocol active or stood down, escalation trigger

source	type
European guideline on major bleeding and coagulopathy after trauma, 6th edition 2023	international guideline
CRASH-2 and WOMAN trials (tranexamic acid, trauma and postpartum); HALT-IT (no benefit in GI bleeding)	randomized trials
AABB 2023 transfusion guideline	international guideline
Andexanet alfa US market withdrawal, Dec 2025	regulatory / safety update

Verify indication, dose, allergies, interactions, renal/hepatic function and local protocols before prescribing.

free the on-call checklist covers the whole shift on one printable page.

studying for the IM exam? the IM Rapid Review covers this in the same format. see the sample chapter.

updated Oct 2026file complaint/massive-hemorrhage