When should I consider referring a patient with major haemorrhage to secondary care?

Consider referring a patient with major haemorrhage to secondary care immediately if they meet any of the following criteria:

• They have lost more than 1 blood volume within 24 hours (approximately 70 ml/kg or more than 5 litres in a 70 kg adult), or have lost 50% of total blood volume in under 3 hours, or are bleeding at a rate exceeding 150 ml/minute in adults.
• They exhibit signs of haemodynamic instability such as a systolic blood pressure less than 90 mmHg or a heart rate greater than 110 beats per minute.
• They have bleeding associated with moderate to severe haemodynamic instability or bleeding that requires red blood cell transfusion beyond routine needs.
• They are on anticoagulant therapy and have active bleeding requiring urgent reversal, necessitating specialist haematology input.
• They require activation of a major haemorrhage protocol based on physiological criteria including haemodynamic status and response to initial volume resuscitation.

Referral should be urgent to enable rapid assessment, reversal of anticoagulation if needed, volume resuscitation, and definitive haemorrhage control including interventional radiology or surgery.

In obstetric cases, any vaginal bleeding other than a 'show' during labour should prompt transfer to obstetric-led care for multidisciplinary management.

Overall, any major haemorrhage with signs of shock, ongoing significant bleeding, or need for blood transfusion warrants immediate referral to secondary care for specialist management.

References: ¹,²,³,⁴