Ok so I asked some of the nursing team in ED what they wanted to know more about, so this one is for you guys! What do we define as ‘major bleeding’ or major haemorrhage’?
For me the way I describe that definition has changed somewhat over the years, in my military days where I was teaching military medics, nurses and doctors before deployment to Afghanistan, I would tell them ‘Bleeding you can hear is bad’.
Nowadays I define major bleeding when asked, as bleeding that is having a physical effect on the patient or making the patient unwell? What things happen to your body when your circulatory system is compromised, what things should we all be routinely checking when we assess ‘C’ in our ABCDE?
Time out #1- List as many signs and symptoms you may expects to see when someone is bleeding badly, and list as many types of major bleeding you can think of… Go
Patients who are truly hypovolaemic from blood loss look unwell, you will spot these people a mile off as they are either wheeled by you on a trolly, or sat in the corridor or even better alerted into resus where you are already prepped and waiting with the pre ordered blood. We are going to have a look at a case study at the end to really cement the scene of these patients and what your role as the ED nurse is. Remember not all patients with blood loos will require blood immediately or fast, so you may triage people who are pale and have very low HB’s but these tend to be treated slightly differently.
First I want to take you back to my first military deployment in Afghanistan with the Royal Air Force in 2010, I was deployed as an ED nurse, having just finished my degree top up in emergency care in Bristol. The build up to going away was quite intense and by that point, the hospital in Camp Bastion had been treating a lot of patients with traumatic injuries resulting in the need for massive transfusion. So there had been a lot of teaching and simulation before going away including numerous drills of how to use the massive transfusion kit, at that time our go to was the the Level 1 Rapid Infuser, never used it check out this video.
We also had a lot of directed education about the real shift in practice which was happening about this time, giving blood to bleeding patients and absolutely avoiding crystalloid, as had been common place in the years preceding this, for those of you as old as me you’ll remember giving 2-3litres of ‘warm crystalloid to trauma patients’, it makes me cringe a bit now to be honest. We practiced putting on tourniquets on real people who had real amputations and worked in medical acting for this exact reason, they are marvellous people and loved taking part in our courses.
One of the actors, who had been an amputee since a very young age. He had a superb make up team with him and they would spend hours making injuries that we could train with. The training was high fidelity and high intensity.
So when I got there it was like learning a dance routine, the way patients were received, handed over, assessed and treated was a drill and it had to be, but this meant everyones role was unique and had to be done well every time. This was one of the hardest things for me to accept in the civilian world, that we didn’t have the time, money or expertise to get a group of staff all to the same level in certain skills.
Anyway back to transfusion, we pre allocated nurses or ODP’s to the role of ‘rapid infuser’ and our job was to get the shock packs and pre load them into the rapid infuser at the right time, the infuser had already been primed with saline and turned on so that the ideal temp of 41 degrees was reached before the blood or FFP was attached – no drop wasted. Back in 2010 our shock pack had 2 units of red blood cells and 2 units of FFP and as soon as a shock pack was called for, the platelets were prepared. Only very occasionally when we had back to back multiple traumas, did I see the lab running out of available stock and it tended to be FFP which they had to wait to defrost. The Americans however, did something then that we are right now looking into with some small trials going on in the UK- the practice of giving whole blood- so not broken down into components of blood just a whole bag out of someones arm with some minor checks.
The first time I helped transfer a bleeding patient on to the trolley, a patient who had already lost a significant amount of blood and was critically unwell, I will never forgot how cold they felt and how pale they looked, it is why I say – if you see someone that looks as though they are bleeding- then they probably are. Then it was straight into role as rapid infuser nurse- and if you are doing this- you ought not to be doing anything else in the trauma team. This role requires complete concentration, dexterity and the ability to listen to what is being said by the trauma team leader, it is them who will be deciding how much blood and in what prescription (i.e which products) we need to give. It’s also really important to keep track of everything that has been given, and keep all of the blood tags ready for return to the labs- *top tip* get an empty sharps bin and put your empty bags and tags in there so that an accurate account of the whole situation can be documented.
The biggest transfusion I did was 122 units, we would very often move with the patient to CT and then theatre and in this case it was so busy in theatre, that there were no ODP’s available to take over. By this time the amount and types of units were being prescribed by the trauma anaesthetist, and based on the ROTEM result- this is a special blood test that some ED’s have access to but often its kept in theatre or maternity and it tells us how the blood is made up, I.e what its missing and so what it is we need to give to improve things and we have a menu to choose from;
Red Blood Cells
Fresh Frozen Plasma
You may have only see RBC and FFP but now more and more centres are starting to change their guidance to truly follow the 1:1:1 approach and some are even thinking it should be 1:1:1:1 (with the final 1 being the cryoprecipitate or cryo). Ultimately its easier and more common to use RBC so you may have seen patients simply have multiple units of this and then a bit FFP at the end. The problem with this is that you are replacing the bath water…. then not putting the plug in, the FFP and platelets and Cryo have the much needed clotting factors that will help your patient to clot and then don’t forget the TXA to preserve that much needed clot that your body is working on. TXA 1g within the first 3 hours and followed by an 8 hour infusion (* Note this is not recommend in GI bleeds where the evidence for a recent study showed it can make outcomes worse*).
I was listening to a brilliant presentation from one of the trauma consultants in my region this week and he was talking about the transfusion as a recipe, quoting that ‘the magic is in the FFP’ so as the ED nurse in charge of transfusion you may be given a recipe of 2 RBC, 2 FFP and 1 Platelets and then we reassess or repeat venous gas. As the nurse remember to ask what shall we give next, have we thought about clotting AND what are we transfusing to… *NB most rapid infusers should not be used for the platelets or cryo*
When I think back to giving very large infusions, most of those patients needed them as they had the types of injuries which are thankfully rare in the UK, in other traumas particularly those with penetrating chest injuries you may only want to give small amounts of blood products to maintain a BP of 80 systolic, especially if you are rapidly heading to theatre, in short don’t over-transfuse and know where you are going.
In terms of equipment needed for rapid transfusion, your rapid infuser of choice, I’ve linked the video to the Level 1 rapid infuser however a lot of trauma centres and units are now using the Belmont Infuser and here is a link to a video on this- sadly not by the @ededucate team on this occasion but thanks to our awesome colleagues at Addenbrooks Major Trauma Centre.
Lets move it forward a few years on my journey and I arrived in my first NHS job where I quickly realised the messages that had almost been tattooed on us in the military hadn’t quite made it everywhere, it quickly earned me the nickname of #BloodNotFluid, and in my roles in both resuscitation training and as an ED sister I tried to spread the learning from the military by sharing literature and stories of my practice. In the end the only thing to do was challenge practice as you see it- respectfully…. “Should this patient have some blood”? and don’t let anyone talk you out of transfusion based on a HB on a venous gas taken in the acute phase.
So I’ve rambled about;
Recognising major bleeding in your patient
Assessing your patient with bleeding
Massive transfusion and products
Knowing when to stop
The rapid infuser
How to advocate good practice in patients who are bleeding
Time for a case…
This is a real case in which I was involved, and names and some details have been changed/withheld to maintain patient and staff confidentiality.
It was 2200 and the first patient I saw on the nightshift had a large swelling in his groin, where he had previously injected drugs, he told me it has bled a lot and had ‘hit the ceiling’ but he applied some pressure and it had settled but now it was causing him pain. This patient was in majors proving not all major bleeds or those at risk of major bleeding will be in resus or alerted in. I was worried this patient may have a pseudo-aneurism- sometimes also called a false aneurism, caused by direct puncture to the vessel causing a swelling/haematoma which has a tract into the artery.
For this guy we got a CT Angiogram of his leg, which looked at the vessels and showed a 7cm false aneurism tract with as very thin layer of tissue, in other words it was high risk of rupturing.
He was seen promptly by the vascular surgeon and we opted to get him a high observation bed in surgery and he was planned for theatre first thing. He didn’t move form ED for a while as there were no high observation bays in surgery which in retrospect was probably a good thing.
At approximately 0130……. It ruptured and I was alerted by the nurse shouting for help and the patient screaming.
Time out #2- What are you thinking? What would your first steps be?
I arrived in the cubicle after a few seconds and immediately donned PPE including a visor, he was bleeding profusely and it was definitely arterial in nature, but remember your own safety here, so task that extra few seconds to get gloves and apron and visor on. The next thing I did was all that any of us can do in the initial minutes of any major bleed where the bleed is external… Apply Direct Pressure
Pressure is best applied with by a smaller surface area, by that I mean you have more chance of stopping the bleeding if you fold the gauze square into 4 so that its a small thick square then if you apply the whole square, this is particularly important if you can see the site of the wound. Think about it how much pressure you can apply in one area when the pressure is applied directly on to the area of bleeding and downwards. If you have never done direct pressure on a bleeding area before, do expect not to get it immediately, its tricky and sometimes you have to adjust and start again which means more blood comes out but results in better pressure applied.
The next question was ‘ok shall we move to resus’? Well what do you guys think should we?
I opted not to move as I had control of the bleeding and the cubicle was plenty big enough and the things that needed to happen;
IV access (he had a very small cannula in…. Remember he had been a previous IVDU)
Initially some TXA on that gauze which you are using to apply pressure, it’s a stop gap and ideally you want some haemostat gauze, sadly we hasn’t finished creating our ‘major haemorrhage box yet’. The the magic happened…
The sister and other nurse from resus appeared in the bedspace with a primed Belmont rapid infuser and told me they had put out the ‘Major Haemorrhage call’ and the first two bags of RBC were being collected now. I won’t go on but essentially our next steps were to transfuse a little amount of blood, ensure he had TXA, alert emergency theatres and the vascular surgeon and plan our move to theatre. That happened and the whole time I didn’t take my hand out of his wound, I tried to hand over to a couple of people and they weren’t able to get control.
This patient did go on to do well although he was in hospital for a long time with wound healing issues but never lost his leg, he is the exact example of patient who we don’t want to over transfuse, he needs the optimal treatment which is an operation by specialist vascular surgeons in theatre and as soon as is humanly possible.
-Be aware for those patients that show you signs that they are bleeding
-Think about the need for blood product resuscitation
-Don’t over transfuse- be the advocate for your patients
-Please please go and practice with your actual equipment so that it comes natural to you when you are stressed/in the heat of the moment
Team of 2 Ready with a primed rapid infuser. *the hands on hips pose is optional*
- The evidence for withholding TXA in upper GI bleeds by the awesome guys at The Resus Room– if you haven’t looked at their website/twitter/podcast before they have a huge catalogue of free education and evidence based medicine that is an absolute must for those working in ED.
- The resus room guys again but this time great podcast on managing external major haemorrhage.
- This is a free blog on RCEMLearning– here you will find lots of content that is free and open access.
CPD Self-Reflection Form Download here