Management of critical bleeding

Critical bleeding is a term used to describe a range of clinical scenarios where bleeding may result in significant morbidity or mortality. In adults it may be defined as:

•    Major haemorrhage that is life-threatening and is likely to result in the need for massive transfusion (≥ 5 units of red blood cells in 4 hours). 
•    Haemorrhage of a smaller volume in a critical area or organ (e.g. intracranial, intraspinal or intraocular), resulting in patient morbidity or mortality.

Massive blood loss in children has been defined as > 35 - 40 mL/kg within 4 hours (blood volume in children over 1 month old is approximately 80 mL/kg). 

Major haemorrhage occurs in settings such as severe bleeding due to trauma, ruptured aortic aneurysm, surgery and obstetrics complications. The goals for the management of major haemorrhage include:

•    Early recognition of blood loss and identification of the cause of bleeding
•    temporary control of bleeding, using: compression, packing, tourniquet, pelvic binder
•    maintenance of tissue perfusion and oxygenation by restoration of blood volume and haemoglobin (Hb)
•    arrest of bleeding including with early surgical or radiological intervention, and
•    timely and balanced administration of blood components to manage coagulopathy.

Major Haemorrhage Protocols (adapted to local requirements and resources) are the standard of care to support a multidisciplinary approach to the appropriate and timely use of blood components and blood conservation strategies to prevent and treat coagulopathy, correct physiological derangement and maintain vital organ perfusion. 

Major haemorrhage management is guided by regular clinical and laboratory assessment according to institutional Major Haemorrhage Protocols. It’s important that physiologic parameters are measure early and frequently, including: temperature, acid-base status, ionised calcium, haemoglobin, platelet count, PT/INR, APTT and fibrinogen. Tranexamic acid is often indicated early (within 3 hours of the onset of haemorrhage) in the management of trauma and obstetric patients with critical bleeding. 

Institutional Major Haemorrhage Protocols will include blood components supplied in locally agreed configurations (ratio-based) or directed by a local viscoelastic haemostatic assay (VHA) guided algorithm.  Institutional ratio‐based adult Major Haemorrhage Protocols should include no fewer than 4 units of fresh frozen plasma and 1 adult unit of platelets for every 8 units of red cells. 

Communication lines between the clinical team and with the transfusion service provider are critical for the timely and appropriate provision of blood components.
The national PBM guidelines on critical bleeding management give further advice for adult patients: Patient blood management guideline for adults with critical bleeding.

In neonatal and paediatric patients refer to institutional age-specific Major Haemorrhage Protocols for activation criteria and management. For more information refer to Module 6 Neonatal and Paediatrics: Patient Blood Management Guidelines.

Indications for blood components in major haemorrhage

Red cells

• Red cell transfusion is likely to be required when 30–40% blood volume is lost (approximately 1,500 - 2,000 mL in an adult male); >40% blood volume loss is immediately life-threatening and requires immediate transfusion.
• Pretransfusion compatibility testing should be done early.
• It’s best practice to transfuse red cells of the same ABO and RhD group as the patient, however if there are insufficient supplies of the patient's ABO group available locally, red cells of another ABO compatible group may be released by the transfusion laboratory.
• If lifesaving transfusion is required prior to confirmation of recipient blood group, group O red cells must be used:
  • Females of childbearing potential (≤ 50 years) and paediatric males ≤ 18 years (or as per local paediatric policy) should receive group O RhD negative red blood cells wherever possible
  • Females > 50 years and all adult males > 18 years may be transfused group O RhD positive red blood cells prior to confirmation of their blood group, according to local policy   

Once the patient’s ABO RhD blood group has been determined using a current valid specimen, transition to ABO‐identical red cells should occur as soon as possible to ensure optimal stewardship of scarce blood components, especially group O RhD negative red cells.

• Should be given through a blood warming device whenever possible.
   

Fresh frozen plasma (FFP)

• Give FFP according to the institutional Major Haemorrhage Protocol (ratio-based or VHA-guided algorithm) to maintain critical targets of PT & APTT ≤ 1.5x the normal range.
• If the patient's blood group is unknown, give group A low-titre (or group AB) FFP according to institutional guidelines.
• Allow 1/2 hour thawing time.
• Extended life plasma (ELP) is an alternative to FFP in this setting.

Fibrinogen replacement

• FFP will not provide adequate fibrinogen to correct hypofibrinogenemia in a critically bleeding patient. Cryoprecipitate should be used according to the institutional Major Haemorrhage Protocol.
• In obstetric haemorrhage, early DIC is often present so consider cryoprecipitate early in this situation.
• Usual adult dose is 3 – 4 g of fibrinogen which is contained in 10 units of whole blood equivalent cryoprecipitate. Your local transfusion laboratory can advise on the number of units to provide this dose.
• Allow up to 1/2 hour thawing time.

Fibrinogen replacement may also be achieved using fibrinogen concentrate – refer to institutional protocols for guidance if available locally.

Platelets

• Thrombocytopenia <50 x 10⁹ /L can be anticipated after two blood volume replacement due to dilution and increased consumption. Follow institutional Major Haemorrhage Protocols to guide initial replacement. 
• Aim to keep the platelet count >50 x 10⁹ /L (higher thresholds may be indicated in some patients such as those with intracranial/spinal bleeding). 
• The usual dose in an adult is 1 unit.

Warfarin reversal

For life-threatening bleeding (including critical organ and intracranial) consensus is to use a combination of Prothrombin Complex Concentrate (PCC) and Vitamin K to reverse warfarin effect.

• Vitamin K: 5 – 10 mg IV in adults 
• Beriplex® (4 factor PCC): 50 IU/kg
  Note: Consider giving a Beriplex® dose < 50 IU/kg when INR 1.5 – 1.9 
• Fresh frozen plasma: 15 mL/kg if PCC is not available. 

FFP is not required for reversal of the warfarin effect as Beriplex® is a 4 Factor PCC and contains all 4 vitamin K-dependent clotting factors. FFP may be required for associated major haemorrhage as directed by the institutional Major Haemorrhage Protocol.

Note: If using remaining supplies of Prothrombinex 3 Factor PCC, refer to local guidelines regarding dosing and the requirement for 150 - 300mL of FPP to deliver Factor VII, if life-threatening bleeding (including critical organ and intracranial).

Updated  February 2025