EMERGENCY

MANAGEMENT OF
BLEEDING
 Take careful history to assess bleeding risk.

History should include.

Patient history of bleeding.
Family history of bleeding.
History of use anticoagulants or
drugs that depress platelet function.

Patient or family history History of anticoagulant or suspect History is entirely

is positive. drug use is positive. negative.

Obtain PT and PTT and assess If anticoagulants are in use stop

platelet function. administartion.
Obtain PT and PTT and assess platelet
function.
Operation is
Operation is
high risk.
low risk.
Obtain PT and
Proceed with
PTT and assess
PT or PTT is abnormal. operation.
PT and PTT platelet function
are normal
Measure levels of specific
coagulation factors.
Correct any coagulation
factor abnormality with
FFP,cryoprecipitate or specific
factor.
Proceed with operation.
PT,PTT, or platelet
PT,PTT, or PT,PTT, or platelet
function is abnormal.
platelet function function is Normal.
is abnormal. Correct any abnormality
Proceed with
with FFP or platelet.
operation.
Transfuse as neccary.
Proceed with operation.

Platelet function
Platelet is abnormal.
function
is normal. Stop suspect
medications.
Proceed with Reassess platelet
operation Emergency procedure. Elective procedure.
function.
Correct any Correct any abnormality Stop suspect medication for 48-72 hr.
residual defect. with FFP or platelets. Verify that defect has been corrected.
With platelet (FFP if Proceed with operation. Proceed with operation
von Willebrand’s
disease is present)
Proceed with
operation.

FIG 1.Algorithm for preoperative screening for bleeding risk

 Disseminated Intravascular coagulation is present.

Laboratory manifestations: fibrinogen level

<100 mg/dl; platelet count < 50.000/ml. D-dimer
level > 500ug/L
Clinical manifestations: massive uncontrollable
oozing secondary bleeding from previously dry
wounds ; secondary bleeding from remote sites.

Initiate treatment.

DIC results from the combination of SHOCK and a clotting

stimulus.
Treatment involves the following simultaneous steps.
Remove clotting stimulus : stop transfusion, and send bag to
blood bank
to check for transfusion reaction.
; remove devitalized tissues ; control sepsis.
Replace coagulation factors : give FFP and platelets.
Treat shock : rapidly infuse balanced salt solution ;
tranfuse red cells to keep hematocrite >20 percent

Bleeding continues.
Bleeding resolves
Give 10.000 U heparin bolus.
Continue giving FFP and platelets.
Maintain vascular volume.

Bleeding resolves Bleeding continues.

Give EACA 1 g I.V. with heparin

(do not give alone ).
Continue giving FFP and platelets.
Maintain vascular volume.

FIG 2.Algorithm for management of disseminated Intravascular coagulation.

 BLEEDING is observed immediately after operation.

The most common causes are (1) an Unligated vessel and (2) Hematologic
problem that developed as a result of the operation.

Patient is UNSTABLE. Patient is STABLE.

Obtain PT and PTT, and assess platelet function. Reasses history, and recheck medication given.
Reoperate immediately,without waiting for test results, Stop transfusion and send remainder of unit to blood bank
to identify source of bleeding. to check for transfusion reaction .
If source cannot be be identified and bleeding is Check body T; if low ,warm patient.
diffuse,treat as instance of intraoperative bleeding (see If bleeding continues, obtain PT and PTT and assess
Fig 2) platelet function.

Platelet function is PT<PTT ,and platelet function are

PT ,PTT and platelet function are PT or PTT is ABNORMAL,and
ABNORMAL.and PT and PTT are NORMAL.
ABNORMAL. platelet function is NORMAL
normal.
REOPERATE to identify source of
Order DIC screen Give FFP
Give PLATELET. bleeding.

DIC screen is NEGATIVE. DIC screen is POSITIVE.

If coagulation defect remains, Treat DIC (see Fig 3)

continue to give platelets and
FFP.

Fig.4 Shown is an algorithm for assessment and management of

POSTOPERATIVE BLEEDING.
 BLEEDING is observed immediately after operation.

The most common causes are (1) an Unligated vessel and (2) Hematologic
problem that developed as a result of the operation.

Patient is UNSTABLE. Patient is STABLE.

Obtain PT and PTT, and assess platelet function. Reasses history, and recheck medication given.
Reoperate immediately,without waiting for test results, Stop transfusion and send remainder of unit to blood bank
to identify source of bleeding. to check for transfusion reaction .
If source cannot be be identified and bleeding is Check body T; if low ,warm patient.
diffuse,treat as instance of intraoperative bleeding (see If bleeding continues, obtain PT and PTT and assess
Fig 2) platelet function.

Platelet function is PT<PTT ,and platelet function are

PT ,PTT and platelet function are PT or PTT is ABNORMAL,and
ABNORMAL.and PT and PTT are NORMAL.
ABNORMAL. platelet function is NORMAL
normal.
REOPERATE to identify source of
Order DIC screen Give FFP
Give PLATELET. bleeding.

DIC screen is NEGATIVE. DIC screen is POSITIVE.

If coagulation defect remains, Treat DIC (see Fig 3)

continue to give platelets and
FFP.

Fig.4 Shown is an algorithm for assessment and management of

POSTOPERATIVE BLEEDING.