Background
Methods
Grade of recommendation | Clarity of risk/benefit | Quality of supporting evidence | Implications |
---|---|---|---|
1A | |||
Strong recommendation, high-quality evidence | Benefits clearly outweigh risk and burdens, or vice versa | RCTs without important limitations or overwhelming evidence from observational studies | Strong recommendation, can apply to most patients in most circumstances without reservation |
1B | |||
Strong recommendation, moderate-quality evidence | Benefits clearly outweigh risk and burdens, or vice versa | RCTs with important limitations (inconsistent results, methodological flaws, indirect or imprecise) or exceptionally strong evidence from observational studies | Strong recommendation, can apply to most patients in most circumstances without reservation |
1C | |||
Strong recommendation, low-quality or very low-quality evidence | Benefits clearly outweigh risk and burdens, or vice versa | Observational studies or case series | Strong recommendation but may change when higher-quality evidence becomes available |
2A | |||
Weak recommendation, high-quality evidence | Benefits closely balanced with risks and burden | RCTs without important limitations or overwhelming evidence from observational studies | Weak recommendation, best action may differ depending on circumstances or patients’ or societal values |
2B | |||
Weak recommendation, moderate-quality evidence | Benefits closely balanced with risks and burden | RCTs with important limitations (inconsistent results, methodological flaws, indirect or imprecise) or exceptionally strong evidence from observational studies | Weak recommendation, best action may differ depending on circumstances or patients’ or societal values |
2C | |||
Weak recommendation, Low-quality or very low-quality evidence | Uncertainty in the estimates of benefits, risks and burden; benefits, risk and burden may be closely balanced | Observational studies or case series | Very weak recommendation; other alternatives may be equally reasonable |
Results
I. Initial resuscitation and prevention of further bleeding
Minimal elapsed time
Recommendation 1
Rationale
Local bleeding management
Recommendation 2
Rationale
Ventilation
Recommendation 3
Rationale
Pre-hospital blood product use
Recommendation 4
II. Diagnosis and monitoring of bleeding
Initial assessment
Recommendation 5
Rationale
Parameter | Class I | Class II (mild) | Class III (moderate) | Class IV (severe) |
---|---|---|---|---|
Approximate blood loss | < 15% | 15–30% | 31–40% | > 40% |
Heart rate | ↔ | ↔/↑ | ↑ | ↑/↑↑ |
Blood pressure | ↔ | ↔ | ↔/↓ | ↓ |
Pulse pressure | ↔ | ↓ | ↓ | ↓ |
Respiratory rate | ↔ | ↔ | ↔/↑ | ↑ |
Urine output | ↔ | ↔ | ↓ | ↓↓ |
Glasgow coma scale score | ↔ | ↔ | ↓ | ↓ |
Base deficit* | 0 to − 2 mEq/L | − 2 to − 6 mEq/L | − 6 to − 10 mEq/L | − 10 mEq/L or less |
Need for blood products | Monitor | Possible | Yes | Massive transfusion protocol |
Immediate intervention
Recommendation 6
Rationale
Further investigation
Recommendation 7
Rationale
Imaging
Recommendation 8
Rationale
Trauma patients with one of the following parameters at hospital arrival: |
Systolic blood pressure < 100 mmHg |
Estimated exterior blood loss ≥ 500 mL |
Glasgow coma scale score ≤ 13 or abnormal pupillary reaction |
AND/OR |
Patients with a clinical suspicion of one of the following diagnoses: |
Fractures of at least two long bones |
Flail chest, open chest, or multiple rib fractures |
Severe abdominal injury |
Pelvic fracture |
Unstable vertebral fractures/spinal cord compression |
AND/OR |
Patients with one of the following injury mechanisms: |
Fall from a height (> 4 m/> 13 ft) |
Wedged or trapped chest/abdomen |
Haemoglobin
Recommendation 9
Rationale
Blood lactate and base deficit
Recommendation 10
Rationale
Coagulation monitoring
Recommendation 11
Rationale
Platelet function monitoring
Recommendation 12
Rationale
III. Tissue oxygenation, volume, fluids and temperature
Volume replacement and target blood pressure
Recommendation 13
Rationale
Vasopressors and inotropic agents
Recommendation 14
Rationale
Type of fluid
Recommendation 15
Rationale
Erythrocytes
Recommendation 16
Rationale
Cell salvage
Recommendation 17
Rationale
Temperature management
Recommendation 18
Rationale
IV. Rapid control of bleeding
Damage control surgery
Recommendation 19
Rationale
Pelvic ring closure and stabilisation
Recommendation 20
Embolisation, packing, surgery and resuscitative endovascular balloon occlusion of the aorta (REBOA)
Recommendation 21
Rationale
Local haemostatic measures
Recommendation 22
Rationale
V. Initial management of bleeding and coagulopathy
Antifibrinolytic agents
Recommendation 23
Rationale
Coagulation support
Recommendation 24
Rationale
Initial coagulation resuscitation
Recommendation 25
-
Fibrinogen concentrate or cryoprecipitate and pRBC (Grade 1C)
-
FFP or pathogen-inactivated FFP in a FFP/pRBC ratio of at least 1:2 as needed (Grade 1C)
Rationale
VI. Further goal-directed coagulation management
Goal-directed therapy
Recommendation 26
Rationale
Fresh frozen plasma-based management
Recommendation 27
Rationale
Coagulation factor concentrate-based management
Recommendation 28
Rationale
Fibrinogen supplementation
Recommendation 29
Rationale
Platelets
Recommendation 30
Rationale
Calcium
Recommendation 31
Rationale
Recombinant activated coagulation factor VII
Recommendation 32
Rationale
VII. Management of antithrombotic agents
Reversal of vitamin K-dependent oral anticoagulants
Recommendation 33
Rationale
Management of direct oral anticoagulants—factor Xa inhibitors
Recommendation 34
Management of direct oral anticoagulants—direct thrombin inhibitors
Recommendation 35
Rationale
Antiplatelet agents
Recommendation 36
Rationale
VIII. Thromboprophylaxis
Thromboprophylaxis
Recommendation 37
Rationale
IX. Guideline implementation and quality control
Guideline implementation
Recommendation 38
Assessment of bleeding control and outcome
Recommendation 39
Rationale
Parameter |
---|
Time from injury to the initiation of intervention to stop bleeding (surgery or embolisation) in hypotensive patients who do not respond to initial resuscitation |
Time from hospital arrival to availability of a full set of blood results [full blood count, prothrombin time, fibrinogen, calcium, viscoelastic testing (if available)] |
Proportion of patients receiving the correct treatment according to the blood results |
Proportion of patients receiving tranexamic acid within 3 h after injury |
Damage control surgical techniques used in accordance with recommendation R19 |
Thromboprophylaxis commenced in accordance with recommendation R37 |