Massive Hemorrhage
ABCs
airway
- assess patency · intubate early if reduced consciousness or ongoing massive bleed
breathing
- high-flow oxygen · monitor SpO₂
circulation
- two large-bore IV lines (14–16 G); if no access → IO
- group & crossmatch · continuous monitoring · send: CBC, PT / INR, APTT, fibrinogen, U&E, calcium, VBG (lactate)
- control visible source → direct pressure / tourniquet / position
- permissive hypotension until source controlled: radial pulse present / SBP ~80–90 (higher in TBI)
activate the major hemorrhage protocol
- ≥1 blood volume in 24 h, ½ blood volume in 3 h, or ongoing bleed with shock
- don’t wait for crossmatch or lab results
HPI & examination
- source · onset · estimated blood loss
- anticoagulant / antiplatelet use · recent surgery / procedure
- trauma · liver disease or coagulopathy
ongoing bleeding
- external · GI · retroperitoneal · surgical site
signs of shock
- tachycardia, hypotension, altered mental status, cool peripheries, prolonged capillary refill
treat
1 · control the bleeding
- direct pressure → endoscopy / IR / surgery; treat source early
2 · transfuse: blood products
| product | target |
|---|---|
| packed red cells | transfuse early, don’t wait for Hb · RBC : FFP : platelets ≈ 1 : 1 : 1 |
| platelets | keep > 50 ×10⁹/L · > 100 in intracranial bleeding |
| fibrinogen | keep > 1.5 g/L · > 2 in obstetric hemorrhage |
| FFP | coagulopathy during active bleeding |
3 · adjuncts
- tranexamic acid: 1 g IV over 10 min, then 1 g over 8 h; give early (within 3 h)
- calcium: replace; monitor ionised Ca (citrate in transfused blood chelates it)
4 · reverse the anticoagulant
| agent | reversal |
|---|---|
| warfarin | PCC + IV vitamin K |
| DOAC | idarucizumab (dabigatran); PCC (favored: andexanet alfa withdrawn from US market Dec 2025 over thrombosis risk; regional availability varies) |
| heparin | protamine |
prevent the lethal triad
- keep warm, correct acidosis + coagulopathy: they amplify each other
- watch for hypocalcemia, hyperkalemia, TRALI / TACO
calculator ABC score (massive transfusion) · MDCalc ↗︎
- persistent shock despite resuscitation + source control → Advanced: Shock, Advanced: Vasopressors & Inotropes
recheck
- monitor: hemoglobin, platelets, fibrinogen, calcium, lactate
- stand down protocol once bleeding controlled; inform lab
evidence
| source | type |
|---|---|
| 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? IM Rapid Review covers transfusion + major bleeding in this format. see the sample chapter.
updated Sep 2026file complaint/massive-hemorrhage