Millions of people experience a life-threatening bleed each year due to an accident or injury, chronic disease, or as an uncommon but significant complication of medicines such as blood thinners.1-3 Management of these bleeds often requires a range of specialists including emergency care clinicians, haematologists, cardiologists, internists, surgeons and pharmacists to coordinate potentially lifesaving treatment in the emergency care setting.4
What is uncontrolled bleeding?
If not effectively managed in the emergency setting, major bleeds can cause serious complications and become life threatening.5 These types of uncontrolled bleeds have led to more than 450,000 deaths globally each year, making it a priority condition to quickly and efficiently manage.6
Uncontrolled bleeding has several underlying causes
There are many reasons someone may experience a life-threatening bleed, ranging from chronic risk factors or a one-time accident or surgery. 5,7 This type of bleeding can happen externally due to lacerations, cuts or punctures, or internally within the body such as inside the brain tissue (intracerebral), skull (intracranial) or gastrointestinal (GI) system.5,7
Physical trauma, such as a car accident, can cause bleeding at critical sites either internally and/or externally.2 People with a potentially higher risk for a bleed include those with chronic conditions.8-12 Certain diseases such as cardiovascular disease, hypertension, Crohn’s disease and irritable bowel syndrome can increase someone’s risk of experiencing bleeding.8-12 Genetic disorders such as haemophilia can also result in uncontrolled bleeding.13
While caring for patients with other cardiovascular conditions and risk factors, clinicians often prescribe blood thinners.14 People with deep vein thrombosis, pulmonary embolism and atrial fibrillation may take these medicines to keep their blood from coagulating and forming clots, which can obstruct blood flow and potentially harm different organs in the body such as the brain, lungs, and heart.14,15
Clinicians prescribe a variety of blood thinners including warfarin and direct oral anticoagulants (DOACs).16 While DOACs are effective and convenient medications and although their benefits outweigh the risks, they carry a small but significant risk of a major bleed developing such as an intracerebral haemorrhage (ICH), GI or non-ICH trauma bleed since the blood is less able to clot.16-18 It is vital medics can coordinate potentially lifesaving care in the emergency setting for these patients.
Emergency clinicians face many challenges while managing uncontrolled bleeds
After a patient arrives at the hospital with a major bleed, emergency medicine clinicians (EMCs) must evaluate whether the patient meets the criteria for a certain care management option.5 Time is of the essence and EMCs must triage and work quickly to implement a strategy.5
Several medical associations including the American College of Cardiology, European Society for Emergency Medicine and American College of Emergency Physicians have established guidelines to help EMCs and hospitals create a management strategy.4,19-20
While all patients experiencing a major bleed require quick attention, it’s vital to specifically identify the patients on anticoagulants.4 These medicines inhibit the body’s natural clotting ability, making it more difficult to manage uncontrolled bleeding.14
To help estimate the risk of major bleeding for patients on blood thinners, a patient’s medical history is reviewed to identify hypertension, abnormal liver or renal function, previous strokes, bleeding history or predisposition, labile INR, age (determine if they’re over the age of 65) and drug or alcohol usage.21 This method is a tool called HAS-BLED and can predict the risk of major bleeding for patients on blood thinners.21 In urgent settings, friends and family members can also provide medical information and help identify those on blood thinners.
Transforming the management of uncontrolled bleeding
Managing uncontrolled bleeding is complex and requires the coordination of care across multiple specialties including emergency medicine clinicians, haematologists, cardiologists, neurologists, surgeons and more.4
The care provided in the emergency setting can be complex, involving rapid decision-making and careful coordination. Guideline-based hospital protocols are vital tools to help cross-disciplinary teams deliver care that could ultimately save a life.
To help all these groups work together, it’s important to establish clear hospital protocols based on pre-existing guidelines that can help clinicians deliver lifesaving care to patients suffering from uncontrolled bleeds. These clinical tools can facilitate information sharing across multidisciplinary teams and help practitioners deliver safer, more effective care. It is also important to establish, whenever possible, dedicated stewardship programs that drive the development, implementation, consistent application, evaluation of care and education of these protocols and guidelines.
At AstraZeneca, we’re committed to transforming care for patients living with cardiovascular, renal and metabolic diseases and highlighting their undertreated and interconnected events such as uncontrolled bleeds. Early detection and care are critical to improving patient outcomes and reducing the burden of cardiovascular, renal and metabolic (CVRM) diseases and their related risks and complications for patients, societies and our planet.
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References
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Veeva ID: Z4-49282
Date of preparation: May 2023