Sun14November1246PM 46

A 75-year-old man presents to A+E with massive haematemesis. He has been taking regular ibuprofen for hip pain for the last three months.

Intravenous access is secured and fluid resuscitation is commenced. He goes on to receive blood product support: 16 units of red cells, 8 units of FFP, 2 adult therapeutic doses of platelets and 2 × 5 adult pools of cryoprecipitate have been given.

He continues to bleed. An urgent clotting screen is requested; the results are shown below:

PT 15.5 secs (12-15)

APTT 35.5 secs (25-35)

Fibrinogen 0.3 g/L (1.5-4)

Hb 105 g/L (130-180)

WCC 3.4 ×109/L (4-11)

Platelets 115 ×109/L (150-400)

Which treatment should be given next?

(Please select 1 option)

Recombinant factor VII (NovoSeven)

FFP Incorrect answer selected

Cryoprecipitate This is the correct answer

Platelets

Prothrombin complex concentrate

Explanation

The fibrinogen level is very low; a fibrinogen level of <0.5 g/L is strongly associated with microvascular bleeding. A fibrinogen level of more than 1 g/L should be aimed for in patients with massive haemorrhage. Cryoprecipitate contains large amounts of fibrinogen and should be given in this situation.

The platelet count should generally be kept above 75-80 ×109/L. FFP should be given if the APTT or PT is >1.5 × mean control.

Local massive haemorrhage protocols should be followed. Recombinant factor VII and prothrombin complex concentrate are unlicensed in this indication and should only be given following specialist advice.