Acute Haemorrhage

Clinical Description

• In massive hemorrhage i.e., from trauma it is difficult to estimate how much blood a patient has lost. However, a good estimate can be made by calculating the patient's normal circulating volume versus vital signs and other organ function tests. See Table 1 below.
• Restoration of blood volume with suitable replacement fluids is more important than red cell replacement in the management of previously healthy patients who have lost under 30% of their blood volume
• The need for blood transfusion must be determined by:
• The amount and speed of blood loss
• The patient’s vital signs

Table 1: Assessment of Blood Loss (For a 70 kg adult)

Stage 1 Stage 2 Stage 3 Stage 4

Blood loss (litres) <0.75 0.75-1.5 1.5-2 >2

Pulse rate <100 >100 >120 >140

BP Normal Normal 90/60 <70

Respiratory Rate <20 >20 >30 >40

Capillary Refill <3 seconds <3 seconds >3 seconds >3 seconds

Mental State Normal Anxious Confused lethargic

Urine output/ Hour >30 mls 20-30 mls <20 mls <10 mls

Replacement fluid vol (L) 2l 2-4.5l >5l plus 2 units blood >6l plus 3 units Blood

• Replacement fluids which may be used are:
• Haemacel: Replace every 1 ml of blood lost with 1 ml of fluid
• Sodium lactate compound (Ringer’s lactate) IV infusion or Normal saline

IV infusion Replace 1 ml of blood lost with 3 mls of fluid.

Do not use dextrose 5% or Darrow's 1⁄2 strength in dextrose 5% as replacement fluids

• Maintain the airway and give oxygen by face mask first, especially for patients in stage 3 and 4. Make sure they are breathing adequately.
• Insert 2 large bore cannula (gauge 14 or 16) and collect blood samples for full blood count (FBC), grouping and cross- matching.
• Give half of the calculated dose of replacement fluid in the first hour and give the other half over 3 hours.
• Always assess the effects of fluid therapy. Remember to give warm fluids and cover patients to avoid hypothermia.
• Aim at improving oxygen carrying capacity first before correcting anaemia.

Remember to add maintenance fluids to the replacement fluid plus any on-going losses.

Maintenance fluids can be calculated as follows:

Adults

Body weight x1.5mls

Children

May use the rule of 4.2.1 for children or refer to section on diarrhoea.

• Remember: deficit + maintenance + on- going loss