| Restore circulating volume |
Insert wide bore peripheral or central cannulae
Give pre-warmed crystalloid or colloid as needed
Avoid hypotension or urine output <0.5 ml/kg/h
|
14 gauge
Monitor central venous pressure
Keep patient warm
Concealed blood loss is often underestimated
|
| Contact key personnel |
Clinician in charge
Consultant anaesthetist
Blood transfusion Biomedical Scientist
Haematologist
|
A named senior person must take responsibility for communication and documentation.
Arrange Intensive Care Unit bed
|
| Arrest bleeding |
Early surgical or obstetric intervention
Interventional radiology
|
|
| Request laboratory investigations |
FBC, PT, APTT, Thrombin time, Fibrinogen (Clauss method); blood bank sample, biochemical profile, blood gases and pulse oximetry
Ensure correct sample identification
Repeat tests after blood component infusion
|
Results may be affected by colloid infusion
Ensure correct patient identification
May need to give components before results available
|
| Maintain Hb >8 g/dl |
Assess degree of urgency |
|
| Employ blood salvage to minimise allogeneic blood use |
Collection of spilt blood can be set up in <10 min |
| Give red cells |
|
Group O Rh D negative |
|
In extreme emergency |
D positive is acceptable if patient is male or postmenopausal female |
Until ABO and Rh D groups known |
ABO group specific when blood group known |
|
Fully compatible blood
Time permitting
|
Further serological crossmatch not required after 1 blood volume replacement |
| Use blood warmer and/or rapid infusion device if flow rate >50 ml/kg/h in adult |
Transfusion laboratory will complete crossmatch after issue |
| Maintain platelet count >75 x 109/l |
Allow for delivery time from blood centre
Anticipate platelet count <50 x 109/l. after 2 x blood volume replacement
|
Allows margin of safety to ensure platelet count >50 x 109/l
Keep platelet count >100 x 109./l if multiple or CNS trauma or if platelet function abnormal
|
| Maintain PT & APTT <1.5 × mean control |
Give FFP 12 to 15 ml/kg (1 l or four units for an adult) guided by tests
Anticipate need for FFP after 1 to 1.5 x blood volume replacement
Allow for 30 min thawing time
|
PT/APTT >1.5 x mean normal value correlates with increased microvascular bleeding
Keep ionised Ca2+ >1.13 mmol/l
|
| Maintain Fibrinogen >1.0 g/l |
If not corrected by FFP give cryoprecipitate (Two packs of pooled cryoprecipitate for an adult)
Should be available on-site. Allow for 30 min thawing time
|
Cryoprecipitate rarely needed except in DIC |
| Avoid DIC |
Treat underlying cause (shock, hypothermia, acidosis) |
Although rare, mortality is high |
