Management of Acute Hemorrhage and Damage-Control Resuscitation: Critical Care Concepts for Interventional Radiologists

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  Identify the severity of blood loss in patients with acute hemorrhage and principles for initial stabilization
  



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  Understand biochemical factors and hemodynamic derangements can cause coagulopathy and clinical deterioration in hemorrhaging patients
  



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  Understand tenets of Damage Control Resuscitation, including evidence-based blood product transfusion guidelines and the role for anticoagulation reversal
  

Interventional Radiologists (IR’s) frequently perform procedures to treat active hemorrhage. These patients may be critically ill with hemorrhagic shock, requiring complex and urgent medical management by the treating IR. Therefore, IR’s should understand the pathophysiology of hemorrhage and evidence-based Damage Control Resuscitation (DCR) guidelines for the non-procedural stabilization of patients in hemorrhagic shock.

Clinical Findings/Procedure Details:

Hemorrhage can lead to inadequate tissue oxygenation, circulatory collapse, and death if uncontrolled. While source control is paramount, immediate hemodynamic resuscitation and counteraction of the “bloody vicious cycle” of coagulopathy, acidosis, and hypothermia is crucial to avoid deterioration.

Initial management includes expeditious recognition of severity of ongoing hemorrhage, imaging diagnosis of source, thermal and metabolic stabilization, and support of cardiac output with IV fluids, blood products, and vasopressors. 

DCR provides an evidence-based, multifaceted management approach to hemorrhage, focusing on correction of coagulopathy and early transfusion of appropriate blood products {1,2}. Warmed blood products should be transfused at an optimal ratio of 1:1:1 pRBCs:FFP:Platelets {2,3}. Institutional massive transfusion protocols facilitate rapid availability and transfusion of large amounts of blood products {2,3}. 

Hemorrhaging patients taking anticoagulant and antiplatelet medications should receive targeted reversal with blood products (eg. FFP, cryoprecipitate) and/or antagonist agents (eg. Idarucizumab, Andexanet alfa) if reversal-associated thrombotic risks do not outweigh benefits {4}.

Conclusion and/or Teaching Points:

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  DCR provides a staged approach to managing severe hemorrhage, focusing on early identification, hemodynamic stabilization, and resuscitation with appropriate blood products
  



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  The “bloody vicious cycle” of coagulopathy, acidosis, and hypothermia should be avoided to prevent clinical deterioration
  



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  Anticoagulant and antiplatelet agents may be counteracted when necessary with blood products and reversal agents.