INITIAL BEDSIDE PRIORITIES
Key Clinical Questions
What are the initial priorities for the patient with severe or life-threatening bleeding?
Is the bleeding medically remediable or does it require structural intervention (interventional radiology or surgery)?
Does the patient have a coagulopathy or a platelet disorder based on history and examination?
What explains an elevated international normalized ratio (INR), an elevated partial thromboplastin time (PTT), and a low platelet count?
How should coagulopathy be managed in the bleeding patient?
If a coagulopathy is present, what should be done to prepare a patient for an invasive procedure?
Initially, the goals for the hospitalist caring for a patient with bleeding should be resuscitation of the unstable patient, control of bleeding, and prevention of further bleeding. Bedside evaluation of patients with apparent brisk bleeding (gastrointestinal, pulmonary, and postpartum) includes vital sign measurement and assessment for adequate perfusion (mentation, capillary refill, urine output). Interpretation of vital sign measurements should take into account the patient’s baseline blood pressure and any medications that may blunt the heart rate response to bleeding. Evidence of hemorrhagic shock mandates aggressive resuscitation using large bore intravenous access for intravenous fluids and blood products.
Life-threatening bleeding events may include intracranial hemorrhage (intracerebral, subdural, epidural, subarachnoid), gastrointestinal hemorrhage, massive hemoptysis, postpartum hemorrhage, and retroperitoneal hemorrhage. Spontaneous intracerebral hemorrhage portends a 25% to 30% in-hospital mortality. Upper gastrointestinal hemorrhage from varices predicts substantial in-hospital mortality.
Similar to management of severe traumatic hemorrhage, the bedside approach should minimize the time between recognition of severe or life-threatening bleeding and bleeding control. Each diagnostic intervention, including history, physical examination, laboratory testing, and radiographic testing, should have the potential to lead directly to therapeutic intervention. The adage of the trauma surgeon that “the only diagnostic test that is absolutely required before operating on the severely injured trauma patient is a type and cross for blood products” emphasizes the absolute focus on intervention that is required for acute, severe bleeding. In general, control of active bleeding requires a multidisciplinary approach that may involve surgery, interventional radiology, and/or endoscopy. Table 78-1 provides guidance regarding the appropriate consultative services to engage urgently for each of the serious or life-threatening hemorrhagic problems along with the anticipated approach.
TABLE 78-1Consultative Approach to Severe Bleeding ||Download (.pdf) TABLE 78-1 Consultative Approach to Severe Bleeding
|Bleeding Event ||Urgent Consultation ||Expected Intervention |
|Spontaneous intracerebral hemorrhage ||Neurosurgery ||Assessment for surgical intervention.* |
Traumatic brain injury associated hemorrhage
|Assessment for surgical intervention.* |
Upper gastrointestinal hemorrhage
Upper gastrointestinal hemorrhage often amenable to endoscopic intervention.
Surgery should be involved in most patients with substantial bleeding and should be consulted early.
|Lower gastrointestinal hemorrhage || |
|Lower gastrointestinal hemorrhage may require angiography for localization and potential intervention....|