Episode Title: Major Bleeding in the ED: A 2025 Practical Guide for Optimal Management

Episode Summary: In this Lit Hit, we break down the comprehensive 2025 review "Major Bleeding in the Emergency Department: A Practical Guide for Optimal Management" and highlight the key evidence emergency clinicians need for rapid, informed decision-making. This short episode delivers high-yield takeaways regarding risk stratification, the "lethal diamond," and specific resuscitation goals that you can apply on your next shift.

What You’ll Learn

• The "Lethal Diamond" replaces the "Lethal Triad": The classic triad of coagulopathy, acidosis, and hypothermia has been updated to include hypocalcemia. Calcium is essential for the coagulation cascade; clinicians should treat hypocalcemia aggressively (ionized calcium < 1.2 mmol/L) using calcium chloride (0.5–1.0 g per 500 mL of transfused blood) to prevent dysrhythmias and coagulation defects.
• Restrictive Fluid Resuscitation is Key: For initial stabilization, use balanced crystalloids rather than saline to avoid hyperchloremic acidosis, and limit volume to a maximum of 1–2 liters. Excessive fluid administration is associated with coagulopathy, organ failure, and increased mortality.
• Targeted Blood Pressure Goals:
• • General/Trauma: Aim for "permissive hypotension" with a systolic blood pressure (SBP) target of 80–90 mmHg until bleeding is controlled.
  • Traumatic Brain Injury (TBI): If GCS < 8, maintain Mean Arterial Pressure (MAP) > 80 mmHg to ensure perfusion.
  • Intracranial Hemorrhage (ICH): Target a SBP of 130–140 mmHg to prevent hematoma expansion.
• Massive Transfusion Ratios: While defined strictly for trauma, massive transfusion protocols (MTP) are recommended for all life-threatening bleeding to prevent delays. Evidence supports a ratio of 1:1:1 or 1:1:2 (plasma:platelets:RBCs).
• Tranexamic Acid (TXA) Indications:
• • Indicated: Trauma (within 3 hours), postpartum hemorrhage, and massive hemoptysis.
  • Not Indicated: Gastrointestinal (GI) bleeding. The HALT-IT study showed no mortality benefit and an increased risk of venous thromboembolism in severe GI bleeding.
• Anticoagulation Reversal Strategy:
• • DOACs: Use specific antidotes if available (Idarucizumab for dabigatran; Andexanet alfa for Xa inhibitors). If unavailable, use 4-factor Prothrombin Complex Concentrate (PCC) at 25–50 IU/kg.
  • Warfarin: PCC is preferred over Fresh Frozen Plasma (FFP) because it reverses INR faster, has lower volume, and avoids ABO cross-matching delays. Administer with Vitamin K.
• Risk Stratification with Shock Index (SI): Because hypotension may not appear until 30% of blood volume is lost, use the Shock Index (HR/SBP). An SI > 0.91 predicts the need for massive transfusion and increased mortality in trauma.

Key Clinical Tip: When managing cirrhotic patients with variceal bleeding, avoid FFP for coagulopathy reversal if possible. FFP adds significant volume, which can increase portal pressure and worsen bleeding. Instead, favor viscoelastic test (VET)-guided use of fibrinogen concentrate or PCC.

Primary Reference: Bezati, S.; Ventoulis, I.; Verras, C.; Boultadakis, A.; Bistola, V.; Sbyrakis, N.; Fraidakis, O.; Papadamou, G.; Fyntanidou, B.; Parissis, J.; et al. Major Bleeding in the Emergency Department: A Practical Guide for Optimal Management. J. Clin. Med. 2025, 14, 784.

Additional Resources:

• European Guideline on Management of Major Bleeding and Coagulopathy Following Trauma (2023)
• British Society of Gastroenterology Guidelines for Upper/Lower GI Bleeding
• International Society on Thrombosis and Haemostasis (ISTH) Guidelines