Assessment and Management of Massive blood loss

  • Massive blood loss is defined as the loss of more than one blood volume in a 24 hour period
    • NB This is an arbitrary definition.  In patients where blood loss is causing haemodynamic compromise, management will be fairly similar
    • One blood volume is ~7% of ideal body weight (e.g. ~5l in a 70kg individual)
    • Other definitions include >50% loss in 3 hours or >150ml/min.


  • NB Most patients with massive haemorrhage will
    • be acutely unwell -> assess using ABCDE approach
    • most will also have an obvious cause of bleeding e.g. trauma, postoperative, obstetrics, obvious GI bleed
      • Note that these may require further specific management


  • Resuscitation
    • Ensure at least one (ideally two) wide bore peripheral cannula(e) and/or central cannula are inserted
      • Give crystalloid or colloid and avoid hypotension/low urine output
        • Ideally pre-warmed
    • Also keep the patient euthermic (i.e. warmed)
  • Blood investigations
    • Ensure Routine bloods (FBC, U&Es, Glucose) plus LFTs, coag screen, crossmatch and group and save
      • Also remember to repeat investigations regularly (certainly after first unit of blood)-
  • Inform senior (usually surgeon involved or on-call staff +/- anaesthetist/ICU) and BTS/Haemorrhage team
    • If the patient is in hypovolaemic shock secondary to blood loss, a shock pack (4 units type specific RBCs, 4 units FFP and 1 unit platelets) can be requested
    • Indications for RBC replacement include:
      • Haemoglobin <60g/l or between 60-100g/l with haemodynamic compromise e.g. tachycardia, hypotension refractory to volume expansion, signs of end-organ ischaemia (e.g. reduced GCS; reduced urine output)
    • Give O- blood if you cannot wait for crossmatching.
    • For each unit of blood given, a unit of FFP should be requested
    • Platelets should be given just to keep platelet count >100×10^9/l

see Blood transfusion

  • Where possible, arrest the bleeding
    • Urgent referral to surgery/theatre in the case of post-operative bleeding; urgent obstetric intervention for obstetric bleeding; urgent endoscopy for upper GI bleeding

A good flow diagram can be found here– NB always refer to local guidance

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