An Approach to the Critically Ill Bleeding Patient

Optimal haemorrhage management, particularly in the case of haemorrhagic shock, requires a distinct set of skills and knowledge as not only are these patients complex, but the application of resuscitation strategies developed for other conditions to them can be counterproductive, even deadly. Key principles for the management of acute haemorrhage include identification of the severity of haemorrhage; selection of tools to identify bleeding sources; determining the urgency of haemorrhage control intervention(s); selection of optimal vascular access; recognition and correction of the causes of impaired haemostasis; and, when appropriate, proper use of anticoagulant reversal agents. Additional (often underappreciated) points of importance are the following: crystalloid and vasopressor use should be minimized in favour of transfusion support; emergency-release blood products are often available if “cross-matching” is delayed; permissive hypotension (SBP 80–90) can help mitigate blood loss (except in TBI scenarios); haemoglobin levels are not useful resuscitation targets in active haemorrhage; hypocalcaemia, hypothermia and acidosis can be deadly in haemorrhage and must be corrected whenever possible; haemorrhage is extremely difficult to control in the setting of active anticoagulants and appropriate reversal agents should be utilized promptly.