The guiding principal should be safe and timely intervention. Patients should be stabilised and if an operation needs to occur in tandem with resuscitation then generally this should be of a damage limitation type procedure rather than definitive surgery (which can be more safely undertaken in a stable patient the following day).

Remember that recent surgery is a contra indication to thrombolysis and that in some patients IV heparin may be preferable to a low molecular weight heparin (easier to reverse).

As a general rule laparotomies for bleeding should follow the core principle of quadrant packing and then subsequent pack removal rather than plunging large clamps into pools of blood. The latter approach invariable worsens the situation is often accompanied by significant visceral injury particularly when done by the inexperienced. If packing controls a situation it is entirely acceptable practice to leave packs in situ and return the patient to ITU for pack removal the subsequent day.