First Aid For Bleeding Or Hemorrhage

[Alix Stocking]

DrStacy Sampson is a family medicine physician who is board certified by the American Osteopathic Board of Family Physicians. She has experience in hospital medicine and utilization management. Dr. Sampson is currently a medical director in the field of payment accuracy and clinical validation.

Marjorie Hecht is a longtime magazine editor/writer, now working as a freelancer on Cape Cod. Her specialties are science, technology, and medicine, but her eclectic career includes being a reporter at the United Nations and covering politics in Washington, D.C. She has an MSW from Columbia University, a BA from Smith College, and she did postgraduate work in race and demography at the London School of Economics.

Bleeding, also called hemorrhage, is the name used to describe blood loss. It can refer to blood loss inside the body, called internal bleeding, or to blood loss outside of the body, called external bleeding.

Blood loss can occur in almost any area of the body. Internal bleeding occurs when blood leaks out through a damaged blood vessel or organ. External bleeding happens when blood exits through a break in the skin.

Remove loose debris and foreign particles from the wound. Leave large items such as knives, arrows, or weapons where they are. Removing these objects can cause further harm and will likely increase the bleeding. In this case, use bandages and pads to keep the object in place and absorb the bleeding.

Paramedics will attempt to control the bleeding before rushing you to the hospital. In some cases, care might be given at home or while on a stretcher. The treatment required will depend on the cause of the bleeding.

Any bleeding that continues without medical treatment could be fatal. For example, if someone has acute bleeding in a short period of time and loses 30 percent or more of their blood volume, they could bleed to death very quickly and would require IV fluid and transfusion of packed red blood cells for resuscitation.

Exsanguination, which is severe bleeding or bleeding to death, can occur without any visible external bleeding. Catastrophic internal hemorrhages can cause a great deal of blood loss, such as ruptured blood vessel aneurysms.

Blood transfusions are a relatively common medical procedure, and while typically safe, there are multiple complications that practitioners need to be able to recognize and treat. This activity reviews the indications for blood transfusion, including for special patient populations, the pre-transfusion preparation, and the potential complications of blood transfusions. In addition, this activity highlights the role of the interprofessional team in caring for patients undergoing blood transfusions.

Objectives:Identify the indications for blood transfusions.Describe the management of blood transfusion complications.Explain the importance of proper pre-transfusion preparation of donor blood to reduce the risk of complications.Review a structured interprofessional team approach to provide effective care to and appropriate surveillance of patients undergoing blood transfusion.Access free multiple choice questions on this topic.

Medicine has made significant progress in understanding circulation in the past few hundred years. For millennia medicine believed in the "four humors" and used bloodletting as a treatment. In the 1600s, William Harvey demonstrated how the circulatory system functioned. Shortly after that, scientists became interested in transfusion, initially transfusing animal blood into humans. Dr. Philip Syng Physick carried out the first human blood transfusion in 1795, and the first transfusion of human blood for treating hemorrhage happened in England in 1818 by Dr. James Blundell.[1] Rapid strides have been made in understanding blood typing, blood components, and storage since the early 1900s. This has developed into the field of transfusion medicine. Transfusion medicine involves laboratory and clinical medicine, and physicians from multiple specialties, such as pathology, hematology, anesthesia, and pediatrics, contribute to the field. Transfusion of red blood cells has become a relatively common procedure. In the United States, around 15 million units are transfused annually, while about 85 million units are transfused worldwide.[2][3][4]

Blood is typically stored in components. Fresh whole blood has always been thought of as the standard for transfusion; however, medical advancement has allowed the efficient use of the different components, such as packed red blood cells (PRBCs), individual factor concentrates, fresh frozen plasma (FFP), platelet concentrates, and cryoprecipitate. Consequently, current indications for whole blood transfusion are generally very few. The US military buddy transfusion system is the most widespread system of whole blood transfusion.[5] Additionally, whole blood transfusion in civilian pre-hospital settings and the trauma bay is seeing a resurgence in some regions. The hemoglobin in red blood cells binds oxygen and is the body's main source of oxygen delivery. A single unit of packed red blood cells is roughly 350 mL and contains about 250 mg of iron.

Guidelines on red blood cell transfusion from the American Association of Blood Banks advise a restrictive approach for stable patients with non-hemorrhaging anemia.[6] While there could be variations, anemia is usually defined as a hemoglobin level of less than 13 g/dL in males and less than 12 g/dL in females. While currently, a more restrictive threshold is used to determine the indication for transfusion, previously, a liberal strategy, typically using a cutoff of hemoglobin less than 10 g/dL, was used, regardless of symptoms.

Currently, guidelines for the transfusion of red blood cells (RBC) generally follow a restrictive threshold. While there is some variation in the number for the threshold, 7 g/dL is an agreed-upon value for asymptomatic healthy patients. Multiple studies have shown this is an acceptable threshold in other patient populations, including those with gastrointestinal (GI) bleeding and critically ill patients. The guidelines recommend a value of 8 g/dL as the threshold in patients with coronary artery disease or those undergoing orthopedic surgeries. However, this may be secondary to the lack of literature on using a threshold of 7 g/dL in the evaluation studies of these patient populations. The guidelines and clinical trials on transfusion requirements in critical care (TRICC) also recommend a value of 7 g/dl as the threshold for critically ill patients.[7][8][9][10]

Transfusion may also be indicated in patients with active or acute bleeding and patients with symptoms related to anemia (for example, tachycardia, weakness, dyspnea on exertion) and hemoglobin less than 8 g/dL.[11] Anemia, in such cases, is described as a decreased circulating red cell mass, defined as grams of hemoglobin per 100 ml of whole blood. Anemia may occur due to external loss, inadequate production, internal destruction, or a combination of these factors. While many patients experiencing active bleeding become anemic, anemia in itself does not become an indication for transfusion. The result of severe hemorrhage is a state of shock, and shock is the insufficient supply of oxygen to carry out cellular metabolism. Red cell mass repletion is one facet of the management of hemorrhagic shock.

Unless the patient is actively bleeding, it is recommended to transfuse 1 unit of packed red cells at a time, which will typically increase the hemoglobin value by 1 g/dL and hematocrit by 3%. Follow up by checking post-transfusion hemoglobin.[12]

The American Society of Anesthesiologists advises transfusion at hemoglobin levels of 6 g/dL or less. However, more recent data show decreased mortality with preanesthetic hemoglobin greater than 8 g/dL, especially in renal transplant patients.[13]

The transfusion of fresh frozen plasma (FFP) is common, but there are limited specific indications for its use. There is insufficient evidence for its use in many clinical scenarios, such as prophylaxis in nonbleeding patients.[14][15][16] FFP transfusion is sometimes indicated in bleeding patients to replace lost coagulation factors. Clinical situations fulfilling this criterion include cardiopulmonary bypass, massive transfusion, decompensated liver disease, extracorporeal pulmonary support techniques, or acute disseminated intravascular coagulation.

In the past, FFP, combined with vitamin K, was indicated for warfarin excess in cases of life-threatening hemorrhage. FFP is rarely needed in vitamin K deficiency or warfarin reversal because prothrombin complex concentrate is widely available.[17]The exception is in the cases of concomitant plasma volume deficit.

Platelet transfusion is beneficial in cases of platelet deficiency or dysfunction. In patients with bone marrow failure, prophylactic platelet transfusion is indicated when there are no other risk factors for bleeding and platelet counts are below 10 X 10/L. If other associated risk factors exist, the threshold to transfuse may be raised to 20 X 10/L. A prerequisite to invasive procedures is platelet counts greater than 50 X 10/L. In the case of active hemorrhage, platelet transfusion should be done when thrombocytopenia contributes to the hemorrhage, and the platelets are less than 50 X 10/L. When there is diffuse microvascular bleeding, the platelets should be maintained above 100 X 10/L.[18][19]

There are no absolute contraindications, but some patients or their patients (in pediatric cases) may refuse to receive transfusions on religious grounds.[20] Whole blood transfusion is not indicated when component-specific treatment is available, such as using red blood cells to treat anemia or using fresh frozen plasma to treat coagulopathy. Whole blood transfusion could lead to many complications, for instance, volume overload, which is why it is advisable to use component therapy whenever possible.

Blood products are transfused through intravenous tubing with filters. The filters, which typically have pore diameters of 170 to 260 microns, are also used to prevent particulate debris from being administered. However, the trapped particulate leads to bacterial growth, and the American Association of Blood Banks (AABB) advises against using a filter for more than four hours. Before transfusion, the tubing should be primed with an isotonic, calcium-free blood-compatible solution, for example, normal saline. Citrate is used as a preservative in packed red blood cells, and clots will form in the intravenous line if there is more calcium than the citrate can buffer.[21]

3a8082e126