Post-operative patient oozing from every puncture site; INR 2.1, platelets 68 × 10⁹/L, fibrinogen 1.1 g/L, temperature 34.8 °C
ABCDE
Stop the bleeding mechanically first, then correct the coagulopathy by its cause. Warm the patient and correct calcium and acidosis — no product works in a cold, acidotic, hypocalcaemic patient.
Identify the mechanism → dilution and consumption after massive transfusion, DIC, liver failure, uraemia, an anticoagulant or antiplatelet drug, or hyperfibrinolysis — the treatment differs for each
Send the right tests → FBC, PT/INR, aPTT, fibrinogen, D-dimer, calcium, and a viscoelastic test (TEG/ROTEM) where available; treat a viscoelastic result in real time rather than waiting for the laboratory
Targets in active major bleeding → fibrinogen above 1.5–2 g/L (cryoprecipitate or fibrinogen concentrate), platelets above 50 × 10⁹/L (above 100 with CNS or ocular bleeding), ionised calcium above 1.1 mmol/L, temperature above 36 °C, pH above 7.2
Tranexamic acid → 1 g IV within 3 hours in trauma and obstetric haemorrhage, then 1 g over 8 hours; not useful once bleeding has stopped, and avoid in established upper GI bleeding where HALT-IT found no benefit
Reverse the drug → warfarin with 4-factor PCC plus vitamin K; dabigatran with idarucizumab; apixaban or rivaroxaban with andexanet alfa or PCC; heparin with protamine; and give platelets for antiplatelet-associated surgical bleeding — but not for intracerebral haemorrhage
Order set
- Group and save, cross-match, activate major haemorrhage protocol
- FBC, PT/INR, aPTT, fibrinogen, D-dimer
- Ionised calcium and blood gas
- TEG/ROTEM if available
- Fluid warmer and forced-air warming
- Tranexamic acid if indicated
- Surgical/endoscopic/radiological source control
Criteria
AdmitAny bleeding needing blood products
ICUMassive transfusion, DIC with organ failure, or bleeding that needs vasopressor support
DischargeBleeding stopped, counts stable off products for 24 h, cause documented
Clinical detail — differentials, red flags, pitfalls, disposition
Red flags
- Oozing from every line site
- Fibrinogen below 1.5 g/L
- Falling platelets with a rising D-dimer
- Ionised calcium below 1.0 mmol/L
Differentials
- DIC
- Dilutional coagulopathy
- Liver failure
- Uraemic platelet dysfunction
- Drug effect
- Heparin-induced thrombocytopenia
- Thrombotic microangiopathy
Common mistakes
- Chasing the INR with FFP in liver disease when the patient is not bleeding
- Forgetting calcium during massive transfusion
- Treating DIC with products instead of treating the trigger
- Transfusing platelets for antiplatelet-related intracerebral haemorrhage
- Leaving the patient cold
Disposition & follow-up
Correct while the source is being controlled; the coagulopathy is a symptom, and it recurs until the surgeon, endoscopist or radiologist has finished.
Discharge package
MedicationsRestart anticoagulation only on a documented plan with a named date
Follow-upHaematology review for unexplained coagulopathy
LifestyleFalls and bleeding risk assessment
Warning symptomsBruising, black stools, blood in urine, sudden severe headache
💊 Treatment detail — doses & preparation
Tranexamic acidantifibrinolytic
Dose1 g IV over 10 min, then 1 g over 8 h
PreparationIn 100 mL saline; give early
MonitorAvoid in known thrombosis; no benefit in GI bleeding
4-factor PCCclotting factor concentrate
Dose25–50 U/kg by INR and indication, with vitamin K 10 mg IV
PreparationReconstituted; small volume, works within 15–30 min
MonitorRecheck INR at 15–30 min; thrombotic risk
Fibrinogen replacementcryoprecipitate or concentrate
DoseCryoprecipitate 10 units, or fibrinogen concentrate 3–4 g, to keep fibrinogen above 1.5–2 g/L
PreparationCryoprecipitate needs thawing — order it early
MonitorRepeat fibrinogen after each dose
📖 BSH major haemorrhage · European trauma bleeding guideline 2023 · ICU chapter 45 · Coagulopathy & the Bleeding PatientReviewed September 2026