Major haemorrhage is a potentially life-threatening but treatable condition.  In order for the patient to receive the best chance of survival with minimal complications, there must be a prompt well co-ordinated response by the clinical team.

These guidelines are derived from those published by the British Standards in Haematology, available at https://b-s-h.org.uk/guidelines/guidelines/haematological-management-of-major-haemorrhage/

Further useful information is available from the Handbook of Transfusion Medicine 5^th Edition, available at https://www.transfusionguidelines.org/transfusion-handbook

Major haemorrhage training is conducted across the staff groups at a local level within clinical areas, based on learning outcomes and objectives set by the HTC and monitored by the HTC on an annual basis. 

Valid definitions of major haemorrhage include:

• Loss of one blood volume within 24 hours
• Loss of 50% blood volume in 3 hours        
• Bleeding at a rate of >= 150 ml/minute           

In practice it is often not possible for accurate measurement of blood loss.  If the clinical team considers that major haemorrhage is taking place this is an emergency situation and senior help must be summoned immediately.

The imperative is to stop bleeding and restore circulating volume before complications develop.

 A)  Stopping the bleeding

Apply direct pressure and consider emergency endoscopy, surgery, or radiological embolisation.

Specific manoeuvres apply in Obstetrics.

In trauma a tourniquet and pelvic binder should be considered.

B)  Restoring circulating volume  

In order to ensure tissue perfusion and oxygenation there must be adequate circulation and oxygen-carrying potential. This is to prevent hypovolaemic shock and multi-organ failure, which carries a high mortality.

Insert 2 large bore (grey 16G or brown 14G if possible) venous cannula and start fluid replacement (calculating per kg. in paediatric patients).

Red cells are the first fluid of choice, however if red cells are not available or delayed then small volumes of crystalloid can be administered to bridge until blood available, preferably Hartmann’s solution to avoid metabolic acidosis associated with large volume of infusion of sodium chloride.

Fluids should be warmed to avoid hypothermia, which increases the risk of end organ failure and coagulopathy. Rapid transfusions must be administered via a rapid infusing device i.e. Belmont Rapid Infuser, which includes a warming facility. The patient must be kept warm. Use blankets and a forced air warmer (e.g. Bair Hugger)

Catheterise the patient as soon as possible.  Aim for urine output of >0.5 ml/kg/hour.  In paediatric patients aim for urine output of >1ml/kg/hr.

Blood required immediately:

Use emergency O negative units.  Two units are always available and may be collected from the blood issue fridge. Inform BTS that these units are being taken to allow BTS staff to re-issue promptly.

Send samples to transfusion laboratory urgently as per major haemorrhage sample pack, which is located in the resuscitation trolley. Samples should be taken prior to the transfusion of O Negative units.

Blood needed urgently:

Send samples to the transfusion laboratory urgently (G+S, FBC, U+E, coagulation screen and lactate).

Group Specific                  10mins from sample receipt          

Electronic Release            5-10mins with suitable sample

Manual X-Match                50mins or more

FFP & Cryoprecipitate      20mins defrost time

Platelets                           1^st pool- immediate

                                         Further pools from Edinburgh

• Any member of the team may call 2222 and initiate the Major haemorrhage protocol, under guidance from a doctor, nurse, midwife or ODP. 
  
  
• Early communication with key staff is essential. The most senior doctor in the parent specialty should be summoned immediately.
  
  
• Switchboard is responsible for initiating the communication cascade (appendix 2)
  
  
• In the event of a major obstetric haemorrhage, a separate ‘Major Obstetric Haemorrhage’ call should be put out which will negate the need to put out two calls (‘Obstetric Emergency’ and ‘Major Haemorrhage’).

Positive patient identification is crucial an emergency situation.  All requests and sample tubes must be labelled with the minimum patient identification data set.  This includes:

Patient’s forename
Patient’s surname
CHI number (or hospital number if not available)
Date of Birth
Sex

In the event of an unknown patient or a major incident, the unique hospital number and gender as a minimum must be referenced.

A major haemorrhage sample pack is available on the resuscitation trolley in each clinical area.  This includes a blood collectionslip, request forms and sample tubes for:

• Transfusion: crossmatch sample
  
  
• Haematology: full blood count, coagulation screen
  
  
• Biochemistry: Urea & electrolytes, lactate

Investigations will need to be repeated as clinically indicated but at least every 4 hours, after 1/3 blood volume replacement or after infusion of FFP.

Following activation of the major haemorrhage protocol, the porter will take blood samples to the transfusion laboratory. The duty Transfusion BMS will prepare a major haemorrhage pack of 4 units of red cells (and 2 units of FFP if required).  Initially two units of red cells will be packaged in a cool box. The porter will wait in the laboratory reception for the blood box for delivery to the clinical area.  The further two units of red cells will be ready and labelled for the patient but will not be sent to clinical area until required, to reduce red cell wastage. In view of the time required to thaw FFP, it is envisaged the 4 units of blood will be delivered in the first instance and the FFP once thawed.

Neonates, infants and children-

Massive blood loss (MBL) related to trauma is uncommon in children. Major bleeding is more common in the surgical setting. The total blood volume in children ranges from 90 mL/kg in term infants down to 70–80 mL/kg in later childhood/adolescence. For simplicity, a figure of 80 mL/kg could reasonably be applied for all children. Massive blood loss may be defined as either 80 mL/kg in 24 h, 40 ml/kg in 3 h or 2–3 ml/kg/min (BSH 2016).  For children aged under the age of 5 the pack will contain 1 unit of red cells (and 1 unit of FFP if required).  Neonatal FFP and cryoprecipitate packs should be available for neonates.. For children aged 5 and over the normal adult pack will be issued.

Transfusion Thresholds

Red Cells: Hb is a poor indicator of acute blood loss and Hb may be well preserved despite significant bleeding. The haemocue can be used to guide transfusion in real time.  Aim to keep Hb>8g/dL subject to clinical judgement.     

Paediatric patient: RBCs 20 mL/kg aliquots (maximum four adult units)

Platelets: anticipate platelet count <50 x 10⁹/L after 1.5 – 2 x blood volume replacement.  Aim to keep platelet count >75 x 10⁹/L. This may require 1 or 2 adult platelet packs.  In ongoing haemorrhage consider platelet transfusion even if platelet count is above 50 x 109/L. Target > 100g/L in case of major trauma, CNS bleeding or abnormal platelet function e.g. Aspirin, renal failure.

Paediatric patient: <15kg give 10-20mL/kg platelets infused over 30-60 minutes. >15kgs give single unit. Platelets in 15–20 ml/kg aliquots (maximum one adult therapeutic dose) to be considered after every 40mL/kg RBCs

PLEASE NOTE: Transfusion laboratory only stocks one unit of platelets. Give as much anticipated notice as possible to the transfusion laboratory as there may be a need to order platelets from SNBTS.

Coagulation status – If 4 units of red cells are required then FFP should also be given. Aim to keep PT and APPT <1.5 x mid point of normal range. This may require further Fresh Frozen Plasma  (FFP) in addition to the 2 units delivered to the patient in the Major Haemorrhage Pack.  The usual dose is 12 – 15mLs/kg, which for an 80kg adult equates to 4 units of FFP.

Paediatric patient:  FFP in 10 -20 mL/kg aliquots (maximum four adult units)

Fibrinogen – aim to keep >1.5 g/L. This may require Cryoprecipitate (Cryo) as advised by the duty Consultant Haematologist.  Cryoprecipitate 10 mL/kg (maximum two pools).

Warfarin reversal: Life and/or limb threathening bleeding in patients on Warfarin should be treated with Prothrombin Complex currently Beriplex. The dose is calculated from the current INR - advice from the Consultant haematologist.

Recombinant factor VII (NovoSeven) may have a role in persistent severe bleeding despite correction with coagulation factors and platelets.  NovoSeven is only effective in the presence of fibrinogen.  Advice is available from the Consultant Haematologist. 

Disseminated Intravascular Coagulation (DIC) This is a potential severe complication of Major Haemorrhage.  The typical sign is micro vascular oozing in the face of organ dysfunction due to micro thrombi in small vessels.  The risk of DIC is greatest in Obstetrics, and where there is massive tissue damage

The lab data suggestive of DIC is prolongation of Prothrombin Time (PT) and Activated Partial Thromboplastin Time (APTT) more than expected by dilution, and significant reduction of platelets and fibrinogen. D-Dimers are typically elevated.

The underlying cause(s) should be treated where possible, and transfusion support with FFP, Cryo and platelets given as appropriate while avoiding circulatory overload.

Tranexamic Acid:   In adults, administer Tranexamic Acid 1g IV (bolus over 10 minutes) followed by 1g infusion over 8 hours.  Seek advice from haematology regarding the use of Tranexamic Acid in children.

1:1:1 Transfusion Policies:  Administration of blood components in a ratio of one unit of red cells to one unit of FFP to one unit of platelets have been used extensively in the military.  These patients represent a different subset of haemorrhage to those, which are commonly seen at the BGH and currently this strategy is not recommended for standard use.  In addition there is only one pool of platelets available at the BGH which, if used will need to be replaced from Edinburgh.

Community Hospitals have significant restrictions to carrying out the above strategies in response to a Major Haemorrhage.  However MH can and does occur in Community Hospitals and it is important to undertake basic resuscitation measures prior to prompt transfer to BGH.

Communication:   Once it has been established that a Major Haemorrhage is occurring a 999 ambulance must be called.  The BGH Emergency Department should be alerted that a patient with significant bleeding is en route so a standby can be prepared.

Management:   Provide 100% oxygen via face mask.  If the bleeding is from a visible site attempt to apply pressure and elevate if appropriate.  Medical Staff or trained nursing staff present at the Community Hospital should attempt cannulation with ideally 2 wide bore cannulae and commence IV fluids (in bleeding the preference is replace with blood, only give small amounts of fluid to bridge until blood available). Samples should be taken for FBC, U&Es and Group and Save.  These should be labelled and sent with the patient in the ambulance. 

It may be necessary to transfer to patient to another hospital with accompanying blood components. To prevent red cell wastage 2 units of red cells are provided for transfer if requested. Only in exceptional circumstances where the patient is unstable; a maximum of 4 units of red cells can be transferred with patient.

Any patient being transferred to another hospital with blood cover must have blood and any components transported in a validated transfer box. It is critical that a member of the clinical team contacts the blood transfusion laboratory on x26248 or bleep 6247 (out of hours).  Additionally, any units which have already been collected and delivered to the clinical area must be returned back to the transfusion laboratory to be packed in validated transport box and documentation for receiving hospital completed.

1. Hypocalcaemia. Transfusion of Red cell concentrate can cause hypocalcaemia and may develop due to haemodilution and impaired hepatic clearance of citrate Administer 10mls IV calcium gluconate if the patient requires 4 or more units RBC transfused.
2. Hyperkalaemia. This may be due to the high extracellular potassium concentration in stored red cell units. This may be worsened by oliguria and metabolic acidosis seen in shock. If >6mmol/l it should be treated with IV glucose and insulin regimes together with bicarbonate to correct acidosis.  Renal support may be needed. Anaesthetist will advise.
3.  Acidosis. This may develop due to tissue underperfusion.
4. Transfusion Associated Circulatory Overload. This can occur when large volumes of blood components are administered and should be managed in a critical care or high dependency setting.

NOTE: THIS DOCUMENT IS NOT EXHAUSTIVE AND INDIVIDUAL DEPARTMENTS MAY HAVE DETAILED PROTOCOLS FOR MAJOR HAEMORRHAGE WITHIN THEIR SPECIALITY WHICH MUST BE REFERRED TO.

MAJOR HAEMORRHAGE INCIDENT
SWITCHBOARD OPERATORS PROCEDURE

There is only one procedure regardless of when the incident occurs.

PROCEDURE

1. The EMERGENCY PHONE (2222) will ring; the caller will state ‘Major Haemorrhage’ and the location of the incident.
   
   
2. On the phone, press the TRANSFER key, then either the MASTER or SLAVE key depending on which console is in use. The caller is now at the console. Put them on hold.
   
   
3. Group page Team(12). Use 20002 as the number for them to call back on.
   
   
4. When Team(12) call in ( it will come in on F11 on the console) connect them to the caller.
   
   
5. Group page Team(13) stating “Major Haemorrhage” and the location number/ward number.

To ensure that patients specific blood transfusion requirements are met: good practice tips for use of irradiated cellular blood components.

1. Hospital/HB transfusion policy needs to include section related to Special requirements and the local processes in place should be included.
   
   
2. Clinical areas and transfusion laboratories must ensure adequate communication about the
   requirement for irradiated components; especially important for shared care across sites/HBs.
   
   
3. Clinical areas /Pharmacy depts. and transfusion laboratories need to agree upon and adopt formal
   process for the “Notification of Need “for special requirements and the provision of irradiated cellular blood components.
   
   
4. The clinical team involved with the patient's care need to identify patients at risk of TA-GvHD/requiring irradiated cellular components.
   
   
5. Clinical teams need to clearly document on transfusion request forms being sent to transfusion
   laboratory (for each individual transfusion episode) the need for irradiated components.
6. Clinical teams need to clearly authorise (prescribe) cellular blood components as irradiated on transfusion record document.
   
   
7. Specific requirements, including need for irradiated blood components, must be part of the bedside check prior to administration of all blood components;this check should be documented.
   
   
8. Laboratory information management systems (LIMS) should be able to maintain record of requirement until removed.
9. The LIMs should prevent selection of non-irradiated cellular components unless appropriate overrides have been authorised.
10. Patients requiring irradiated components should be informed of the need and the reasons for this –they should also be provided with appropriate written guidance using the recommended NSS/SNBTS produced patient information leaflet (PIL) ( please click on link ) irradiated_blood.pdf (nhs.scot).
    
    
11. Where possible patients should be encouraged to carry the tear off “Special requirement-irradiated cellular component” advice card (see PIL link above) to facilitate provision of appropriate components.
    
    
12. Clinical teams need to inform the transfusion laboratory, when there are changes in patients clinical need for irradiated cellular blood components, so that protocol can be amended or removed from LIMs.