Neurosurgery notes/Pharmacology/Anti-platelet-coagulation/Major haemorrhage

Major haemorrhage

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Anti-platelet-coagulation

General

  • Blood volume
      • Age
      Approx. blood volumes
      Premature neonate
      90-105 ml/kg
      Term neonate
      80-90 ml/kg
      Child
      70-80 ml/kg
      Male adolescent
      70 ml/kg
      Female adolescent
      65 ml/kg

Classification

Factor
Class I
Class II
Class III
Class IV
Blood loss
<15% (<750 mL)
15–30% (750–1500 mL)
30–40% (1500–2000 mL)
>40% (>2000 mL)
Pulse
>100
>100
>120
>140
Blood pressure
Normal
Normal
↓
↓↓
Pulse pressure
Normal or ↓
↓
↓↓
↓↓
Capillary refill
<2 s
2–3 s
3–4 s
>5 s
Respiratory rate
14–20
20–30
30–40
>40
Urine output (mL/h)
≥30
20–30
5–10
Negligible
Mental status
Slightly anxious
Mildly anxious
Anxious and confused
Confused, lethargic
  • Tennis score

Send blood samples

  • Emergency crossmatch: 6 units of red cells (RBC) will be made available – request as appropriate
  • FBC
  • Clotting screen including
    • Fibrinogen.
  • ROTEM (rotational thromboelastometry) or TEG (thromboelastography)
  • Biochemistry including calcium
  • Group O blood will be issued unless there is a second sample available to confirm blood group.
    • Group O negative will always be issued for females <50 years.
    • O negative or O positive may be issued for male patients and females over the age of 50 years.
  • Consider requirement for ABGs

Give blood products as appropriate

  • Trauma Packs
    • Pack A
      • 6 units of RBC
      • 4 units of FFP
      • +/- Platelets
    • Pack B
      • 4 units RBC
      • 4 units of FFP
      • 1 unit of platelets
      • 2 pools of Cryopercipitate
  • Blood products
    • RBC
      • 6 units
      • Decision to use O negative, group specific or fully cross-matched blood is a clinical one.
        • Please note: Blood bank may issue O positive blood for male patients and females over the age of 50 years in an emergency.
    • Where the patient being transfused has special requirements, it may be necessary to discuss with the Blood Transfusion lab +/- a Haematologist if there are problems fulfilling these requirements in order for the best available blood to be issued.
    • Worried about DIC
      • In trauma: 4 units of fresh frozen plasma (FFP) will be thawed for use on request.
  • Platelets
    • Needs to be requested separately
  • Patients on anti-thrombotic therapy
    • Warfarin
      • Prothrombin complex concentrate should be administered.
    • Direct oral anticoagulants (DOACS - apixaban, dabigatran, edoxaban, or rivaroxaban)
      • Discuss with a Haematologist regarding specific reversal agents available.

Guidance

Blood product
Important information
Red cells
- Aim haemoglobin >70 g/L (7 g/dL)
- O negative from blood bank or satellite fridges
- Group specific 25 min
- Full crossmatch 60 min.
Clotting factors
- Fresh frozen plasma (FFP): aim PT and APTT <1.5× control (PT <18 s and APTT <45 s)
- Cryoprecipitate: aim fibrinogen >1.5 g/L
Platelets
- Aim platelet count >50×10⁹/L, or >100×10⁹/L if multiple injuries or CNS trauma
- Stocks held at Gartnavel so may take >1 hour to arrive.

In massive transfusion remember

  • Allow at least
    • 20 minutes for thawing of plasma products
    • 25 minutes for group specific red cells
    • Up to 60 minutes for full crossmatch unless antibodies are present in which case least incompatible will be issued
    • Transport time

Other information

  • If emergency O negative used please inform Haematology / Blood Transfusion lab as soon as possible to ensure replacement of units.
  • Avoid wastage of blood products - return blood immediately to the Blood Transfusion lab or satellite fridge if not being used.
  • Packed red cells should not be lying out of fridge for more than 30 minutes.
    • If a unit of blood will not be used in that time, it should be returned to the blood fridge, if however this has not occurred the unit can be transfused up to 4 hours from removal from fridge to minimise wastage.
  • Once situation resolved, inform lab staff and porters to allow them to stand down.
  • Once cycle completed review clinical situation.
  • Tranexamic acid
    • Safely reduce the risk of death in bleeding trauma patients (CRASH 2 Trial).
    • Dose is tranexamic acid IV 1g over 10 minutes, then infusion of 1g over 8 hours.
    • Recent HALT-IT study has shown that there is no benefit in the use of tranexamic acid in gastric bleeds.

Massive transfusion

  • Can lead to the following
    • Volume overload resulting in non-cardiogenic pulmonary edema
    • Thrombocytopenia
      • Following storage there is a reduction of functioning platelets, so that there is a dilutional thrombocytopenia following a large transfusion
    • Coagulation factor deficiency (relative)
      • Leading to a coagulopathy if concomitant cryoprecipitate/FFP not also transfused.
    • Ineffective tissue oxygenation due to reduced volume of 2,3 bisphosphoglycerate, which does not store well
    • Hypothermia
      • Unless blood adequately warmed
    • Hypocalcemia
      • Due to chelation by the citrate in the additive solution and may worsen coagulopathy
    • Hyperkalemia
      • Due to progressive potassium leakage from the stored red cells
  • Does not lead to
    • Iron overload