Massive haemorrhage

• Blunt trauma: Commonly due to road traffic accidents, falls, or assaults; often results in internal bleeding (e.g., splenic rupture, liver laceration, or pelvic fracture).
• Penetrating trauma: Injuries from stabbings or gunshots; may cause massive hemorrhage from major blood vessels or organs.
• Long bone fractures: Particularly femoral fractures, which can result in significant blood loss into the thigh compartment.

• Gastrointestinal bleeding: Causes include peptic ulcer disease, variceal hemorrhage, and diverticular disease; presents with hematemesis, melena, or hematochezia.
• Ruptured aortic aneurysm: Sudden onset of severe abdominal or back pain with signs of shock; high mortality if not treated emergently.
• Postpartum hemorrhage: Significant blood loss following childbirth, often due to uterine atony, retained placenta, or trauma during delivery.
• Ruptured ectopic pregnancy: Presents with abdominal pain, vaginal bleeding, and signs of hypovolemic shock; a gynecological emergency.
• Disseminated intravascular coagulation (DIC): A condition that can occur in sepsis, trauma, or malignancy, leading to widespread bleeding and microthrombi.

Symptoms such as dizziness, palpitations, chest pain, breathlessness, and syncope are indicative of hypovolemic shock, commonly seen in massive hemorrhage.

A history of recent trauma, surgery, or invasive procedures raises the suspicion of internal bleeding or surgical complications, such as an anastomotic leak or vessel injury.

Symptoms such as hematemesis, melena, or hematochezia suggest gastrointestinal bleeding. Associated symptoms may include epigastric pain or history of liver disease.

In females, a history of recent pregnancy, childbirth, or ectopic pregnancy should be explored, as these are key causes of hemorrhage.

• Past medical history: Look for a history of bleeding disorders, liver disease, or previous aneurysms.
• Drug history: Use of anticoagulants, antiplatelets, or NSAIDs can increase the risk of bleeding.
• Family history: Inherited bleeding disorders such as hemophilia or von Willebrand disease may be relevant.
• Social history: Alcohol use can predispose to gastrointestinal bleeding, particularly variceal hemorrhage in the context of liver cirrhosis.

• Full blood count: To assess hemoglobin levels and the degree of anemia.
• Coagulation profile: Including PT, APTT, and fibrinogen levels to evaluate coagulopathy.
• Crossmatch: For urgent blood transfusion if necessary.
• Urea and electrolytes: To assess renal function, which may be compromised in shock.
• Liver function tests: Particularly important if liver disease is suspected as a contributing factor to the hemorrhage.
• Arterial blood gas (ABG): To assess acid-base status, lactate levels (marker of tissue hypoperfusion), and oxygenation.

• Focused Assessment with Sonography for Trauma (FAST): To quickly assess for internal bleeding in trauma patients, particularly in the abdomen and pericardium.
• CT scan: With or without contrast, to identify the source of hemorrhage, particularly in non-traumatic cases (e.g., ruptured aneurysm, GI bleed).
• Endoscopy: Upper or lower GI endoscopy may be required to identify the source of gastrointestinal bleeding.
• Pelvic ultrasound: Especially in cases of suspected ruptured ectopic pregnancy or postpartum hemorrhage.
• Angiography: Can be both diagnostic and therapeutic, particularly in GI bleeding or pelvic trauma.

• Thromboelastography (TEG): To assess the efficiency of blood coagulation and guide the management of coagulopathies.
• Laparotomy or thoracotomy: Surgical exploration may be required in cases of uncontrollable hemorrhage where the source is not identified by other means.
• Diagnostic peritoneal lavage (DPL): An older method used to detect intra-abdominal bleeding in trauma, now largely replaced by FAST.