Synopsis
Recognise major traumatic bleeding before profound hypotension, control accessible sources, activate coordinated blood-component support, and move rapidly to definitive operative or radiological haemostasis.
- Control visible catastrophic bleeding first with firm direct pressure, wound packing or an approved tourniquet; record tourniquet placement and application time clearly.
- Search the chest, abdomen, pelvis, retroperitoneum and long bones for concealed loss; a small external wound does not explain away abnormal physiology.
- Activate the major-haemorrhage protocol from clinical suspicion and response, not after laboratory confirmation, and state the delivery location and responsible clinician.
- Use blood components in the locally specified balanced pack, minimise crystalloid during active bleeding and obtain rapid definitive source control through surgery, embolisation or both.
- Give tranexamic acid as soon as possible: adult trauma regimen 1 g IV over 10 minutes then 1 g over 8 hours, with treatment started within 3 hours of injury.
- Prevent the lethal physiology of coagulopathy by active warming, warmed blood, serial fibrinogen or viscoelastic assessment and repeated ionised-calcium measurement with protocol-led replacement.
- Take samples before transfusion if this causes no delay, but never wait for a normal early haemoglobin, INR or platelet count before controlling obvious major bleeding.
- Stand down the protocol explicitly once haemostasis and physiology are credible, notify transfusion, reconcile unused components and continue surveillance for recurrent bleeding and transfusion harm.
Key red flags
Uncontrolled external bleeding, expanding swelling, traumatic amputation, suspected pelvic disruption or blood loss into chest or abdomen requires immediate haemorrhage-control action.
Altered mental state, cool mottled skin, delayed refill, tachypnoea, narrowing pulse pressure, rising lactate or base deficit may identify shock before systolic hypotension develops.
Recurrent instability after blood, continued drain or wound loss, falling fibrinogen, prolonged clot initiation or low ionised calcium indicates resuscitation failure and ongoing bleeding until proven otherwise.
Investigation priorities
Quantify perfusion and rapidly identify calcium, potassium and acid-base danger.
Guide targeted haemostatic replacement during active major bleeding.
Management branches
Life-threatening bleeding is seen or strongly suspected from mechanism and physiology.
- Apply direct pressure, haemostatic packing or a tourniquet as anatomically appropriate, splint long-bone injury and position a pelvic binder over the greater trochanters when indicated.
- Call the major-haemorrhage protocol with patient identifiers and location, obtain large-bore intravenous or intraosseous access and send urgent blood samples without delaying transfusion.
- Begin warmed blood-component support, administer timely tranexamic acid and prevent heat loss while the team identifies the likely internal source.
- Request senior trauma, anaesthetic, surgical, interventional-radiology and transfusion input early and select the shortest safe route to haemorrhage control.