Management of Bleeding Following Major Trauma: An Updated European Guideline

Rolf Rossaint; Bertil Bouillon; Vladimir Cerny; Timothy J Coats; Jacques Duranteau; Enrique Fernández-Mondéjar; Beverley J Hunt; Radko Komadina; Giuseppe Nardi; Edmund Neugebauer; Yves Ozier; Louis Riddez; Arthur Schultz; Philip F Stahel; Jean-Louis Vincent; Donat R Spahn

Disclosures

Crit Care. 2010;14(2):R52 

In This Article

Abstract and Introduction

Abstract

Introduction Evidence-based recommendations are needed to guide the acute management of the bleeding trauma patient, which when implemented may improve patient outcomes.
Methods The multidisciplinary Task Force for Advanced Bleeding Care in Trauma was formed in 2005 with the aim of developing a guideline for the management of bleeding following severe injury. This document presents an updated version of the guideline published by the group in 2007. Recommendations were formulated using a nominal group process, the Grading of Recommendations Assessment, Development and Evaluation (GRADE) hierarchy of evidence and based on a systematic review of published literature.
Results Key changes encompassed in this version of the guideline include new recommendations on coagulation support and monitoring and the appropriate use of local haemostatic measures, tourniquets, calcium and desmopressin in the bleeding trauma patient. The remaining recommendations have been reevaluated and graded based on literature published since the last edition of the guideline. Consideration was also given to changes in clinical practice that have taken place during this time period as a result of both new evidence and changes in the general availability of relevant agents and technologies.
Conclusions This guideline provides an evidence-based multidisciplinary approach to the management of critically injured bleeding trauma patients.

Introduction

Uncontrolled post-traumatic bleeding is the leading cause of potentially preventable death among trauma patients.[1,2] About one-third of all trauma patients with bleeding present with a coagulopathy on hospital admission.[3–5] This subset of patients has a significantly increased incidence of multiple organ failure and death compared to patients with similar injury patterns in the absence of a coagulopathy.[3,5,6] Appropriate management of the trauma patient with massive bleeding, defined here as the loss of one blood volume within 24 hours or the loss of 0.5 blood volumes within 3 hours, includes the early identification of potential bleeding sources followed by prompt measures to minimise blood loss, restore tissue perfusion and achieve haemodynamic stability. Confounding factors include co-morbidities, pre-medication and physical parameters that contribute to a coagulopathic state.[7,8]

The early acute coagulopathy associated with traumatic injury has recently been recognised as a multifactorial primary condition that results from a combination of shock, tissue injury-related thrombin generation and the activation of anticoagulant and fibrinolytic pathways. The condition is influenced by environmental and therapeutic factors that contribute to acidaemia, hypothermia, dilution, hypoperfusion and haemostasis factor consumption.[3,4,8–11] A number of terms have been proposed to describe the condition, which is distinct from disseminated intravascular coagulation, including acute traumatic coagulopathy,[4] early coagulopathy of trauma,[5] acute coagulopathy of trauma-shock[8] and trauma-induced coagulopathy.[12] With the evolution of the concept of an early post-traumatic coagulopathic state, it may be appropriate to reassess some data from the past, and with time new research will doubtless lead to a better understanding of the risks and benefits of different therapeutic approaches applied to this group of patients.

In 2007, we published a European guideline for the management of bleeding following major trauma that included recommendations for specific interventions to identify and control bleeding sources using surgical, physiological and pharmacological strategies.[13] The guideline was developed by a multidisciplinary group of European experts, including designated representatives from relevant professional societies, to guide the clinician in the early phases of treatment. Here we present an updated version of the guideline that incorporates a renewed critical survey of the evidence published during the intervening three years and a consideration of changes in clinical practice that have taken place based on technologies that have become more widely available and pharmacological agents that have entered or left the market. Although the level of scientific evidence has improved in some areas, other areas remain devoid of high-level evidence, which may never exist for practical or ethical reasons. The formulation and grading of the recommendations presented here are therefore weighted to reflect both this reality and the current state-of-the-art.

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