Management of bleeding and coagulopathy following major trauma: an updated European guideline

Abstract

IntroductionEvidence-based recommendations are needed to guide the acute management of the bleeding trauma patient. When these recommendations are implemented patient outcomes may be improved.MethodsThe 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 represents an updated version of the guideline published by the group in 2007 and updated in 2010. 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.ResultsKey changes encompassed in this version of the guideline include new recommendations on the appropriate use of vasopressors and inotropic agents, and reflect an awareness of the growing number of patients in the population at large treated with antiplatelet agents and/or oral anticoagulants. The current guideline also includes recommendations and a discussion of thromboprophylactic strategies for all patients following traumatic injury. The most significant addition is a new section that discusses the need for every institution to develop, implement and adhere to an evidence-based clinical protocol to manage traumatically injured patients. The remaining recommendations have been re-evaluated 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.ConclusionsA comprehensive, multidisciplinary approach to trauma care and mechanisms with which to ensure that established protocols are consistently implemented will ensure a uniform and high standard of care across Europe and beyond.Please see related letter by Morel et alhttp://ccforum.com/content/17/4/442

Rotational Thromboelastometry as a Routine Point-of-Care Test Immediately after Cardiopulmonary Bypass Facilitated Earlier Diagnosis of Unexpected Hyperfibrinolysis and Hypofibrinogenemia During Cardiac Surgery

“…In the present case, hypofibrinogenemia and lack of other factors for the clot formation cascade were promptly diagnosed by MCF < 7 mm in FIBTEM and managed by timely transfusion of cryoprecipitate. Fibrinogen is the first factor that is typically depleted during massive bleeding and hemodilution [13] and suggested to maintain 1.5-1.8 g/L [11,14]. Meanwhile, the conventional indirect Clauss method is not reliable to determine the fibrinogen level in the use of heparin as in the present case (Figure-2).…”

Management of Critical Bleeding in Trauma Patients: Between Recommendations and Reality

“…According to the European guidelines for management of bleeding and coagulopathy following major trauma [16] routine detection of post-traumatic coagulopathy which includes early repeated and combined measurement of PTT, aPTT, fibrinogen and PTL are recommended. Viscoelastic methods may also be performed to help characterize the coagulopathy and in guiding/ management of haemostatic therapy.…”

“…According to the European guidelines, [16] monitoring and coagulation support should start as early as possible. Complete and rapid monitoring of blood coagulation and fibrinolysis using viscoelastic methods may facilitate a more accurate targeting of therapy.…”

Relationship between initial fibrinogen level with coagulopathy and mortality in multiple trauma patients

“…Fibrinogen supplementation should be given when the value of fibrinogen is under 1 g/L, but some research proves that the value of fibrinogen under 2 g/L will give bad impact for the patients. [16][17][18] The most current scoring for trauma is using Injury Severity Score (ISS). ISS is a complex scoring system that summarizes patients data into one of numerical data.…”