GENERAL SURGERY

Abnormal Bleeding and Coagulopathies

• Resuscitation of the bleeding patient with isotonic saline solutions will rapidly dilute and deplete the clotting system.
• In patients who respond to fluids but appear to have continued moderate blood loss, angiography and embolization may be of value in stopping continued bleeding if deemed not to be surgically controllable.
• Prevention and correction of acidosis and hypothermia is essential for the optimal function of platelets and clotting factors.
• In the stable patient, using coagulation studies to guide component replacement is effective.
• However, in the face of massive hemorrhage, awaiting coagulation studies will prolong the duration of shock and coagulopathy.
• It is vital to anticipate the need for blood products. Patients arriving with a significant base deficit or ongoing hemorrhage will require FFP, platelets, and/or cryoprecipitate.
• Blood products and the best ICU care will not take the place of adequate surgical control of hemorrhage.
• Damage control procedures in the injured patient should be performed prior to the onset of coagulopathy. High-risk patients have an injury severity score >25, pH < 7.3, T < 35_C, systolic blood pressure <90 mmHg, base deficit >6, and lactate >4 mmol/l.