FFinalistSouthampton · 2027
Acute care
AKT · Acute care/Resuscitation & shock

Major haemorrhage

Acute blood loss → hypovolaemic shock + coagulopathy

Overview

Rapid large-volume blood loss causing hypovolaemic shock, coagulopathy and risk of death. Managed by activating the major haemorrhage protocol, controlling the source, and giving blood + tranexamic acid early.

Recognise

  • Visible/concealed bleeding (GI, trauma, obstetric, ruptured AAA, ectopic)
  • Tachycardia then hypotension (young patients compensate then crash), cool clammy, oliguria
  • Coagulopathy, hypothermia and acidosis = the "lethal triad"

Red flags

  • Young patients maintain BP until late then decompensate suddenly; concealed bleeding (retroperitoneal, GI, intra-abdominal)

Differentials & how to tell them apart

Distributive (septic) shockinfective source, warm peripheries — not blood loss
Cardiogenic shockpump failure, raised JVP
Ruptured AAA / ectopicspecific concealed-bleed sources to actively exclude

Investigations

ABCDE; group & crossmatch, FBC, clotting/fibrinogen, lactate, ABG; identify the source (FAST/CT, endoscopy).

Management

Activate major haemorrhage protocol; control source; tranexamic acid + balanced blood products

  1. 1ABCDE, direct pressure / control the source, activate the major haemorrhage protocol; give tranexamic acid early and balanced blood products (avoid large crystalloid volumes).Gate: Give tranexamic acid within 3 hours of traumatic/obstetric haemorrhage — later than that it may be harmful
  2. 2Definitive source control (surgery, endoscopy, interventional radiology); correct hypothermia/acidosis; permissive hypotension in uncontrolled trauma haemorrhage.
Tranexamic acid — 1 g IV early (within 3 h of trauma/PPH) — antifibrinolytic
Blood products (major haemorrhage protocol) — red cells + FFP + platelets in balanced ratio; cryoprecipitate for low fibrinogen

Key points

Avoid over-transfusing clear fluids (dilutional coagulopathy). The lethal triad — coagulopathy, hypothermia, acidosis — must be actively prevented.

Monitor & prognosis

Serial Hb/lactate/clotting, fibrinogen, temperature; response to source control.

Depends on speed of source control and balanced resuscitation.

Source: NICE NG39 (major trauma); CRASH-2 (tranexamic acid)