Nonsurgical management of major hemorrhage

Major hemorrhage is life-threatening and can occur in a variety of clinical settings. For the purpose of this review, we defined major hemorrhage as life-threatening bleeding that is likely to result in the need for massive transfusion (i.e., ≥ 10 units of red blood cells in 24 h).1,2 We did not use the commonly used definition of major bleeding from the International Society on Thrombosis and Haemostasis because some bleeding events in the score do not need transfusion (e.g., intraocular or intra-articular bleeding, a 20 g/L decrease in hemoglobin levels).3 Management of major hemorrhage is most challenging in rural settings where the availability of blood products and specialized laboratory tests are limited. The response to major hemorrhage is labour-intensive and requires the support of a multidisciplinary team. Best practice for patients with major hemorrhage is now informed by numerous randomized controlled trials (RCT), as shown in Table 1, which allowed the development of standardized massive hemorrhage protocols (MHPs). However, implementation of and adherence to MHPs has been a challenge. We review the evidence for management of major hemorrhage and MHPs to support the implementation of such protocols at all hospital types to optimize the care of patients with major hemorrhage (Box 1).17,18