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
Rationale
Tourniquet use
Rationale
Ventilation
Rationale
II. Diagnosis and monitoring of bleeding
Initial assessment
Rationale
Class I | Class II | Class III | Class IV | |
---|---|---|---|---|
Blood loss (ml) | Up to 750 | 750–1500 | 1500–2000 | >2000 |
Blood loss (% blood volume) | Up to 15 % | 15–30 % | 30–40 % | >40 % |
Pulse rate (bpm) | <100 | 100–120 | 120–140 | >140 |
Systolic blood pressure | Normal | Normal | Decreased | Decreased |
Pulse pressure (mmHg) | Normal or increased | Decreased | Decreased | Decreased |
Respiratory rate | 14–20 | 20–30 | 30–40 | >35 |
Urine output (ml/h) | >30 | 20–30 | 5–15 | Negligible |
CNS/mental status | Slightly anxious | Mildly anxious | Anxious, confused | Confused, lethargic |
Initial fluid replacement | Crystalloid | Crystalloid | Crystalloid and blood | Crystalloid and blood |
Rapid response | Transient response | Minimal or no response | |
---|---|---|---|
Vital signs | Return to normal | Transient improvement, recurrence of decreased blood pressure and increased heart rate | Remain abnormal |
Estimated blood loss | Minimal (10–20 %) | Moderate and ongoing (20–40 %) | Severe (>40 %) |
Need for more crystalloid | Low | Low to moderate | Moderate as a bridge to transfusion |
Need for blood | Low | Moderate to high | Immediate |
Blood preparation | Type and crossmatch | Type-specific | Emergency blood release |
Need for operative intervention | Possibly | Likely | Highly likely |
Early presence of surgeon | Yes | Yes | Yes |
Immediate intervention
Rationale
Further investigation
Rationale
Imaging
Intervention
Further assessment
Rationale
Haemoglobin
Rationale
Serum lactate and base deficit
Rationale
Coagulation monitoring
Rationale
III. Tissue oxygenation, type of fluid and temperature management
Tissue oxygenation
Restricted volume replacement
Vasopressors and inotropic agents
Rationale
Type of fluid
Rationale
Erythrocytes
Rationale
Temperature management
Rationale
IV. Rapid control of bleeding
Damage control surgery
Rationale
Pelvic ring closure and stabilisation
Packing, embolisation and surgery
Rationale
Local haemostatic measures
Rationale
-
Collagen-based agents trigger platelet aggregation, resulting in clot formation when in contact with a bleeding surface. They are often combined with a procoagulant substance such as thrombin to enhance the haemostatic effect. A positive haemostatic effect has been shown in several human studies [360‐363].
-
Gelatin-based products can be used alone or in combination with a procoagulant substance [353]. Swelling of the gelatin in contact with blood reduces the blood flow and, in combination with a thrombin-based component, enhances haemostasis [357‐359]. The products have been successfully used for local bleeding control in brain or thyroid surgery when electrocautery may cause damage to nerves [356] or to control bleeding from irregular surfaces such as post-sinus surgery [355].
-
Absorbable cellulose-based haemostatic agents have been widely used to treat bleeding for many years, and case reports as well as a prospective observational human study support their effectiveness [368]. The oxidised cellulose-based product can be impregnated with polyethylene glycol and other salts and achieve comparable and more rapid haemostasis compared to the combined products described below [367].
-
Polysaccharide-based haemostatics can be divided into two broad categories [353]: N-acetyl-glucosamine-containing glycosaminoglycans purified from microalgae and diatoms and microporous polysaccharide haemospheres produced from potato starch. The mechanism of action is complex and depends on the purity or combination with other substances such as cellulose or fibrin. A number of different products in the form of pads, patches or bandages are currently available and have been shown to be efficient for external use and for splanchnic bleeding in animals. An observational study showed that haemorrhage control was achieved using a poly-N-acetyl glucosamine-based bandage applied to ten patients with severe hepatic and abdominal injuries, acidosis and clinical coagulopathy [369].
V. Initial management of bleeding and coagulopathy
Coagulation support
Rationale
Initial coagulation resuscitation
-
Plasma (FFP or pathogen-inactivated plasma) in a plasma–RBC ratio of at least 1:2 as needed. (Grade 1B)
-
Fibrinogen concentrate and RBC according to Hb level. (Grade 1C)
Rationale
Antifibrinolytic agents
Rationale
VI. Further resuscitation
Goal-directed therapy
Rationale
Fresh frozen plasma
Rationale
Fibrinogen and cryoprecipitate
Rationale
Platelets
Rationale
Calcium
Rationale
Antiplatelet agents
Rationale
Desmopressin
Rationale
Prothrombin complex concentrate
Rationale
Direct oral anticoagulants – factor Xa inhibitors
Direct oral anticoagulants – thrombin inhibitors
Rationale
Recombinant activated coagulation factor VII
Rationale
Thromboprophylaxis
Rationale
VII. Guideline implementation and quality control
Guideline implementation
Assessment of bleeding control and outcome
Rationale
Treatment phase | Yes | No | N/A | Reason for variance | |
---|---|---|---|---|---|
Initial assessment and management | |||||
Extent of traumatic haemorrhage assessed | ☐ | ☐ | ☐ | ||
Patient in shock with identified source of bleeding treated immediately | ☐ | ☐ | ☐ | ||
Patient in shock with unidentified source of bleeding sent for further investigation | ☐ | ☐ | ☐ | ||
Coagulation, haematocrit, serum lactate, base deficit assessed | ☐ | ☐ | ☐ | ||
Antifibrinolytic therapy initiated | ☐ | ☐ | ☐ | ||
Patient history of anticoagulant therapy assessed (vitamin K antagonists, antiplatelet agents, oral anticoagulants) | ☐ | ☐ | ☐ | ||
Resuscitation | |||||
Systolic blood pressure of 80–90 mmHg achieved in absence of traumatic brain injury | ☐ | ☐ | ☐ | ||
Measures to achieve normothermia implemented | ☐ | ☐ | ☐ | ||
Target haemoglobin level 7–9 g/dl achieved | ☐ | ☐ | ☐ | ||
Surgical intervention | |||||
Abdominal bleeding control achieved | ☐ | ☐ | ☐ | ||
Pelvic ring closed and stabilised | ☐ | ☐ | ☐ | ||
Peritoneal packing, angiographic embolisation or surgical bleeding control completed in haemodynamically unstable patient | ☐ | ☐ | ☐ | ||
Damage control surgery performed in haemodynamically unstable patient | ☐ | ☐ | ☐ | ||
Local haemostatic measures applied | ☐ | ☐ | ☐ | ||
Thromboprophylactic therapy recommended | ☐ | ☐ | ☐ | ||
Coagulation management | |||||
Coagulation, haematocrit, serum lactate, base deficit, calcium reassessed | ☐ | ☐ | ☐ | ||
Target fibrinogen level 1.5–2 g/l achieved | ☐ | ☐ | ☐ | ||
Target platelet level achieved | ☐ | ☐ | ☐ | ||
Prothrombin complex concentrate administered if indicated due to vitamin K antagonist, oral anticoagulant or evidence from viscoelastic monitoring | ☐ | ☐ | ☐ |
Pre-hospital bundle | Intra-hospital bundle | Coagulation bundle |
---|---|---|
• Pre-hospital time minimised • Tourniquet employed in case of life-threatening bleeding from extremities • Damage control resuscitation concept applied • Trauma patient transferred directly to an adequate trauma specialty centre | • Full blood count, prothrombin time, fibrinogen, calcium, viscoelastic testing, lactate, BE and pH assessed within the first 15 min • Immediate intervention applied in patients with haemorrhagic shock and an identified source of bleeding unless initial resuscitation measures are successful • Immediate further investigation undertaken using focused assessment with sonography for trauma (FAST), computed tomography (CT) or immediate surgery if massive intra-abdominal bleeding is present in patients presenting with haemorrhagic shock and an unidentified source of bleeding • Damage control surgery concept applied if shock or coagulopathy are present • Damage control resuscitation concept continued until the bleeding source is identified and controlled • Restrictive erythrocyte transfusion strategy (haemoglobin 7–9 g/dl) applied | • Tranexamic acid administered as early as possible • Acidosis, hypothermia and hypocalcaemia treated • Fibrinogen maintained at 1.5–2 g/l • Platelets maintained at >100 × 109/l • Prothrombin complex concentrate administered in patients pre-treated with warfarin or direct-acting oral coagulants (until antidotes are available) |
-
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, PT, fibrinogen, calcium, viscoelastic testing (if available)].
-
Proportion of patients receiving TXA within 3 h after injury.
-
Time from hospital arrival to CT scan in bleeding patients without an obvious source of haemorrhage.
-
Damage control surgical techniques used in accordance with Recommendation 19.
-
Thromboprophylaxis commenced in accordance with Recommendation 37.
Discussion
Conclusions
Key messages
-
Traumatically injured patients should be transported as quickly as possible and treated by a specialised trauma centre whenever possible.
-
Measures to monitor and support coagulation should be initiated as early as possible and used to guide resuscitation.
-
A damage control approach to surgical intervention should guide patient management.
-
Awareness of potential thrombotic risk and pre-treatment with anticoagulant agents, particularly in older patients, should be part of routine clinical management.
-
Local adherence to a multidisciplinary, evidence-based treatment protocol should serve as the cornerstone of patient management and undergo regular quality assessment.