NHS Lanarkshire Major Haemorrhage Protocol

Hairmyres Hospital version

For obstetric haemorrhage please see Obstetric Haemorrhage Guideline. Check patient does not have an advance directive refusing blood and blood products. Major haemorrhage = blood loss >150ml / min or 50% blood vol in 3 hours or 1 blood vol in 24 hours or any worrying, uncontrolled bleeding Blood volume = 70ml / kg in adults (80ml / kg in children), average adult 5 litres. Goal Resuscitate Get help (See phone numbers below) Restore circulating volume Laboratory tests Action Airway, Breathing (ensure high flow oxygen), Circulation (see below) Declare massive haemorrhage Designate a coordinator Junior staff contact seniors early. Insert wide bore peripheral cannulae x 2. Give warmed crystalloid / colloid infusions using pressure bags. Fluid therapy guided by BP, HR and peripheral perfusion. Inform laboratory prior to sending. Urgent FBC, U&Es, Ca2+, clotting screen, ABGs, Cross-match 8 units initially. Ensure correct patient identification. Plan definitive therapy. Elevate and compress bleeding extremity. Emergency group O neg, 4 units kept in Blood Transfusion lab - use only in emergencies until Group specific available Group specific - 10 mins to issue. Fully cross-matched - 30 mins to issue. Aim to maintain Hb >8. Use a blood warmer. Sa02, BP, HR, hourly urine output, temperature, ECG. Catheterise. Consider CVP/ arterial lines, HDU care. Repeat FBC, U+Es, Ca2+, clotting screen & ABGs regularly - at least every 4 hours or after infusion of clotting factors. Discuss with haematologist if anticipating loss of 1 blood volume. Aim: PTR / APTR 1.5x control. Dose: 12-15ml/kg (approx 4 units for adults). Allow 20 mins for thawing. Aim: allow safety margin to ensure platelets maintained >50x109/L or >100x109/L in multiple / CNS trauma / abnormal platelet function e.g. aspirin. Dose: 1 pool for adults. Order early allowing 45 mins to obtain from SNBTS. Aim: fibrinogen 1.0g / L. Dose: 2 pools for adults. Allow 20 mins for thawing Recombinant FVIIa (Novoseven), Prothrombin complex concentrate (warfarin reversal), Protamine (heparin reversal), Vitamin K, Antifibrinolytics

Arrest bleeding Request suitable red cells

Institute monitoring

Correct clotting: FFP Platelets

Cryoprecipitate Consider other agents

Inform haematology when bleeding under control. See commentary for further details.
Anaesthetic team Surgical team Medical team Blood bank Haematologist dect 5731, ICU dect 4578 dect 5696, (out of hours HECT nurse 5304) dect 4570, (out of hours HECT nurse 5303) dect 4311, 4317 (out of hours via switchboard) dect 4320 (out of hours via switchboard)

NHS Lanarkshire Major Haemorrhage Protocol

Wishaw Hospital version
For obstetric haemorrhage please see Obstetric Haemorrhage Guideline. Check patient does not have an advance directive refusing blood and blood products. Major haemorrhage = blood loss >150ml / min or 50% blood vol in 3 hours or 1 blood vol in 24 hours or any worrying, uncontrolled bleeding Blood volume = 70ml / kg in adults (80ml / kg in children), average adult 5 litres. Goal Resuscitate Get help (See phone numbers below) Restore circulating volume Laboratory tests Action Airway, Breathing (ensure high flow oxygen), Circulation (see below) Declare massive haemorrhage Designate a coordinator Junior staff contact seniors early. Insert wide bore peripheral cannulae x 2. Give warmed crystalloid / colloid infusions using pressure bags. Fluid therapy guided by BP, HR and peripheral perfusion. Inform laboratory prior to sending. Urgent FBC, U&Es, Ca2+, clotting screen, ABGs, Cross-match 8 units initially. Ensure correct patient identification. Plan definitive therapy. Elevate and compress bleeding extremity. Emergency group O neg, 4 units kept in Laboratory Matched Blood Fridge - use only in emergencies until Group specific available, contact switchboard using 2222 to make the request. No patient details are required for this call. Group specific - 10 mins to issue. Fully cross-matched - 30 mins to issue. Aim to maintain Hb >8. Use a blood warmer. Sa02, BP, HR, hourly urine output, temperature, ECG. Catheterise. Consider CVP/ arterial lines, HDU care. Repeat FBC, U+Es, Ca2+, clotting screen & ABGs regularly - at least every 4 hours or after infusion of clotting factors. Discuss with haematologist if anticipating loss of 1 blood volume. Aim: PT18.5 secs, APTT48 secs. Dose: 12-15ml/kg (approx 4 units for adults). Allow 20 mins for thawing. Aim: allow safety margin to ensure platelets maintained >50x109/L or >100x109/L in multiple / CNS trauma / abnormal platelet function e.g. aspirin. Dose: 1 pool for adults. 1 pool held in stock. Allow 45 mins to obtain further stock from SNBTS. Aim: fibrinogen 1.0g / L. Dose: 2 pools for adults. Allow 20 mins for thawing Recombinant FVIIa (Novoseven), Prothrombin complex concentrate (warfarin reversal), Protamine (heparin reversal), Vitamin K, Antifibrinolytics

Arrest bleeding Request suitable red cells

Institute monitoring

Correct clotting: FFP Platelets

Cryoprecipitate Consider other agents

Inform haematology when bleeding under control. See commentary for further details.
Anaesthetic team Surgical team Medical team Blood bank Haematologist Page 003; Page 290; Page 002; Page 062; Page 065; ACCU Ext. 6748 Phone 6461 Phone 6808 Phone 7262 (out of hours 6446) (out of hours via switchboard)

NHS Lanarkshire Major Haemorrhage Protocol

Monklands Hospital version
For obstetric haemorrhage please see Obstetric Haemorrhage Guideline. Check patient does not have an advance directive refusing blood and blood products. Major haemorrhage = blood loss >150ml / min or 50% blood vol in 3 hours or 1 blood vol in 24 hours or any worrying, uncontrolled bleeding Blood volume = 70ml / kg in adults (80ml / kg in children), average adult 5 litres. Goal Resuscitate Get help (See phone numbers below) Restore circulating volume Laboratory tests Action Airway, Breathing (ensure high flow oxygen), Circulation (see below) Declare massive haemorrhage Designate a coordinator Junior staff contact seniors early. Insert wide bore peripheral cannulae x 2. Give warmed crystalloid / colloid infusions using pressure bags. Fluid therapy guided by BP, HR and peripheral perfusion. Inform laboratory prior to sending. Urgent FBC, U&Es, Ca2+, clotting screen, ABGs, Cross-match 8 units initially. Ensure correct patient identification. Plan definitive therapy. Elevate and compress bleeding extremity. Emergency group O neg, 4 units kept in Blood Transfusion lab - use only in emergencies until Group specific available Group specific - 10 mins to issue. Fully cross-matched - 30 mins to issue. Aim to maintain Hb >8. Use a blood warmer. Sa02, BP, HR, hourly urine output, temperature, ECG. Catheterise. Consider CVP/ arterial lines, HDU care. Repeat FBC, U+Es, Ca2+, clotting screen & ABGs regularly - at least every 4 hours or after infusion of clotting factors. Discuss with haematologist if anticipating loss of 1 blood volume. Aim: PTR / APTR 1.5x control. Dose: 12-15ml/kg (approx 4 units for adults). Allow 20 mins for thawing. Aim: allow safety margin to ensure platelets maintained >50x109/L or >100x109/L in multiple / CNS trauma / abnormal platelet function e.g. aspirin. Dose: 1 pool for adults. Order early allowing 45 mins to obtain from SNBTS. Aim: fibrinogen 1.0g / L. Dose: 2 pools for adults. Allow 20 mins for thawing Recombinant FVIIa (Novoseven), Prothrombin complex concentrate (warfarin reversal), Protamine (heparin reversal), Vitamin K, Antifibrinolytics

Arrest bleeding Request suitable red cells

Institute monitoring

Correct clotting: FFP Platelets

Cryoprecipitate Consider other agents

Inform haematology when bleeding under control. See commentary for further details.
Anaesthetic team Surgical team Medical team Blood bank Haematologist Page 103 Page 119 (out of hours HECT nurse Page 862) Page 109 (out of hours HECT nurse Page 861) Ext 2102 (out of hours Page 139) Page 281 (out of hours via switchboard)