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Review
. 2023 Jun 5;195(22):E773-E781.
doi: 10.1503/cmaj.221731.

Nonsurgical management of major hemorrhage

Jeannie Callum  1 , Christopher C D Evans  2 , Alan Barkun  2 , Keyvan Karkouti  2
Affiliations
Review

Nonsurgical management of major hemorrhage

Jeannie Callum et al. CMAJ. .

Erratum in

No abstract available

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Conflict of interest statement

Competing interests: Jeannie Callum has received research funding from Canadian Blood Services (produces and distributes blood components) and Octapharma (manufactures prothrombin complex concentrate and fibrinogen concentrates). She sits on the nominating committee with the Association for the Advancement of Blood & Biotherapies, and on the data safety monitoring boards for the TRACE (Tranexamic Acid for Subdural Hematoma) trial, a University of Ottawa pilot study of tranexamic acid for hypoproliferative thrombocytopenia, and the FEISTY (fibrinogen replacement in trauma) trial. Alan Barkun has received reimbursement for consulting from AstraZeneca and Medtronic. Keyvan Karkouti has received research funding, consulting fees and honoraria from Octapharma, and consulting fees from Werfen (provides viscoelastic point of care testing). He sits on review boards with the Canadian Institutes of Health Research and the Heart and Stroke Foundation. No other competing interests were declared.

Figures

Figure 1:
Figure 1:
Algorithm to guide activation of the massive hemorrhage protocol in patients with major hemorrhage. A Critical Administration Threshold (CAT) score of 3 or higher (CAT 3+) is defined as the need for transfusion of 3 or more red blood cells in the first hour of resuscitation. A Resuscitation Intensity (RI) score of 4 or higher is defined as the need for 4 or more of any of the following in the first 30 minutes: unit of blood (red cell, plasma or platelet), 500 mL of colloid or 1000 mL of crystalloid. The shock index is calculated as the heart rate divided by systolic blood pressure.
Figure 2:
Figure 2:
Use of tranexamic acid for major hemorrhage. Note: IV = intravenous.
Figure 3:
Figure 3:
Frequency of laboratory testing and hemostatic targets. *No suggested target in patients with cirrhosis. †More than 100 × 109/L for patients with head injury. ‡More than 2.0 g/L for postpartum hemorrhage. Note: INR = international normalized ratio.
Figure 4:
Figure 4:
Algorithm for a generic massive hemorrhage protocol for patients with major bleeding. A Critical Administration Threshold (CAT) score of 3 or higher (CAT 3+) is defined as the need for transfusion of 3 or more red blood cells in the first hour of resuscitation. A Resuscitation Intensity (RI) score of 4 or higher is defined as the need for 4 or more of any of the following in the first 30 min: unit of blood (red cell, plasma or platelet), 500 mL of colloid or 1000 mL of crystalloid. The shock index is calculated as the heart rate divided by systolic blood pressure. *If plasma is unavailable in rural settings, consider 2000 IU prothrombin complex concentrate (PCC) and 4 g of fibrinogen; avoid the use of plasma in patients with cirrhosis. †Reversal is not recommended for patients with gastrointestinal (GI) bleeding unless hemorrhage is life-threatening. ‡No suggested target for patients with cirrhosis. §>2.0 g/L for postpartum hemorrhage. Note: INR = international normalized ratio, IV = intravenous, RBC = red blood cells.
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References

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