Massive haemorrhage overview

6 min read Last updated April 8, 2026

Why massive haemorrhage matters

  • Major bleeding can kill quickly from shock (not enough circulating blood) and from coagulopathy (blood not clotting).
  • Early action saves lives: call for help, stop the bleeding, and replace blood components in a balanced way.
  • Anaesthesia team roles often include: airway/ventilation, vascular access, transfusion coordination, temperature control, and communication with surgeons/obstetrics/ED/ICU.

Definitions (keep it simple)

  • Massive haemorrhage = life-threatening bleeding requiring urgent blood component replacement and senior/multidisciplinary input.
  • Common practical triggers: ongoing uncontrolled bleeding, haemodynamic instability despite fluids, or anticipated need for large-volume transfusion.
  • Massive Transfusion Protocol (MTP) / Massive Haemorrhage Protocol (MHP) = a pre-planned hospital pathway to rapidly deliver blood products, labs, and support.

Recognise early: clinical cues

  • Shock signs: tachycardia, hypotension, cool peripheries, delayed capillary refill, reduced urine output, altered mental state (if awake).
  • Bleeding clues: visible blood loss, expanding haematoma, surgical field flooding, persistent vaginal bleeding, GI bleed with instability, trauma with multiple injuries.
  • Lab/monitor clues: rising lactate/base deficit, falling Hb (may lag early), worsening acidosis, low fibrinogen, prolonged PT/APTT, low platelets.
  • Remember: normal BP can be misleading early (especially young/fit patients).

First 5 minutes: what to do

  • Call for help early: senior anaesthetist, theatre/ED/obstetric team, haematology/transfusion lab, porters/runners, ICU.
  • Activate the hospital MHP/MTP (know the local number/bleep and where the protocol lives).
  • Stop the bleeding: urgent surgical control, interventional radiology, uterotonics/obstetric measures, pelvic binder/tourniquet where appropriate.
  • Airway and breathing: give high-flow oxygen; secure airway early if deteriorating, ongoing bleeding, or reduced consciousness.
  • Circulation: get large-bore access (2 x wide cannulas) and/or rapid infusion catheter; consider early arterial line for beat-to-beat BP and blood sampling; consider central access if needed for rapid infusion/vasopressors.
  • Send urgent bloods: group & screen/crossmatch, FBC, PT/APTT, fibrinogen, U&E, calcium, VBG/ABG with lactate; repeat frequently.
  • Warm the patient and fluids: forced-air warmer, fluid warmer, warmed blood; prevent hypothermia (it worsens clotting).

Balanced transfusion: what you are aiming for

  • Aim to replace what is being lost: red cells (oxygen carrying), plasma (clotting factors), platelets, and fibrinogen (key early clotting protein).
  • Use your local MHP packs (often RBC + FFP + platelets in set ratios) while waiting for lab results.
  • Fibrinogen falls early in major bleeding (especially obstetrics/trauma): treat low fibrinogen promptly with cryoprecipitate or fibrinogen concentrate as per local policy.
  • Avoid large volumes of cold crystalloid: it dilutes clotting factors and worsens hypothermia and acidosis.

Tranexamic acid (TXA)

  • TXA reduces bleeding by inhibiting clot breakdown (antifibrinolytic).
  • Give early when major haemorrhage is suspected (especially trauma and postpartum haemorrhage), ideally within 3 hours of onset.
  • Typical adult dosing used in many protocols: 1 g IV over 10 minutes then 1 g IV over 8 hours (follow local guideline).

Key physiology: the ‘lethal triad’ (and what to do about it)

  • Hypothermia: warm patient, warm blood/fluids, minimise exposure, use active warming early.
  • Acidosis: restore perfusion (blood components and haemorrhage control); avoid excessive crystalloid; optimise ventilation/oxygenation.
  • Coagulopathy: activate MHP, give balanced components, correct fibrinogen/platelets, consider guided therapy (TEG/ROTEM) if available.

Calcium and potassium: common transfusion issues

  • Citrate in blood products can cause low ionised calcium, leading to hypotension and poor clotting.
  • Check ionised calcium early and regularly during MHP; replace calcium as per local protocol (e.g., calcium chloride via central line or calcium gluconate peripherally).
  • Watch potassium: stored blood can be high in potassium; monitor ECG and blood gases, especially in rapid/high-volume transfusion.

Communication and teamwork (often the difference between chaos and control)

  • Nominate a team leader and a transfusion ‘runner’ to liaise with the lab and collect products.
  • Use closed-loop communication: confirm instructions and read back critical information (e.g., product type, patient identifiers).
  • Document times and volumes: activation time, products given, TXA, calcium, key labs, estimated blood loss, urine output.
  • Escalate early to ICU for ongoing resuscitation or post-op care.

After initial control: ongoing targets and monitoring

  • Reassess frequently: BP, HR, capillary refill, mental state, urine output, temperature, lactate/base deficit.
  • Repeat labs/point-of-care tests regularly; adjust components based on results and clinical picture.
  • Plan for de-escalation: stop MHP when bleeding controlled and transfusion needs stabilise; ensure handover includes products given and outstanding results.
  • Consider complications: transfusion reactions, TRALI/TACO, hypocalcaemia, hypothermia, dilutional coagulopathy, abdominal compartment syndrome (trauma), DIC (obstetrics/sepsis).
When should I activate the Massive Haemorrhage Protocol?

Activate early if bleeding is life-threatening or likely to need rapid large-volume transfusion. – Ongoing uncontrolled bleeding – Shock despite initial measures – Senior concern/anticipated major blood loss If unsure, activate and stand down later.

What are my first actions as the anaesthetist?

– Call for senior help and activate MHP – Secure airway/oxygenation as needed – Get rapid large-bore access and send urgent bloods – Start warming and prepare rapid transfusion – Coordinate with surgeons/obstetrics to stop bleeding

Why not just give lots of crystalloid while waiting for blood?

Large volumes of crystalloid: – Dilute clotting factors and platelets – Worsen hypothermia and acidosis – Can increase bleeding by raising blood pressure before haemorrhage control Use small boluses if needed, but prioritise blood components and haemorrhage control.

What is ‘balanced transfusion’ in simple terms?

Replacing red cells plus clotting support (plasma, platelets, fibrinogen) early, rather than red cells alone, to prevent/limit coagulopathy.

What labs should I send and how often?

Send early and repeat frequently (often every 30–60 min in active bleeding): – FBC (Hb/platelets) – PT/APTT and fibrinogen – Blood gas with lactate and ionised calcium – Group & screen/crossmatch

Why is fibrinogen important?

Fibrinogen is a key building block of clot. It can drop early in major haemorrhage (especially obstetrics/trauma). Low fibrinogen needs prompt replacement (cryo or fibrinogen concentrate) as per local protocol.

When should I give tranexamic acid (TXA)?

Give as early as possible when major haemorrhage is suspected (especially trauma and postpartum haemorrhage), ideally within 3 hours of onset. Use local dosing guidance.

Why do we check calcium during massive transfusion?

Citrate in transfused blood binds calcium. – Low ionised calcium can cause hypotension and reduced clotting. Check on blood gases and replace calcium as per local protocol.

What are common transfusion complications to watch for during MHP?

– Hypothermia, hypocalcaemia, hyperkalaemia – Transfusion reactions (fever, rash, hypotension) – TRALI (acute hypoxia) and TACO (fluid overload) – Ongoing coagulopathy despite transfusion (consider TEG/ROTEM-guided therapy if available)

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