The European guideline on management of major bleeding and coagulopathy following trauma: fifth edition

Abstract

Background: Severe traumatic injury continues to present challenges to healthcare systems around the world, and post-traumatic bleeding remains a leading cause of potentially preventable death among injured patients. Now in its fifth edition, this document aims to provide guidance on the management of major bleeding and coagulopathy following traumatic injury and encourages adaptation of the guiding principles described here to individual institutional circumstances and resources. Methods: The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma was founded in 2004, and the current author group included representatives of six relevant European professional societies. The group applied a structured, evidence-based consensus approach to address scientific queries that served as the basis for each recommendation and supporting rationale. Expert opinion and current clinical practice were also considered, particularly in areas in which randomised clinical trials have not or cannot be performed. Existing recommendations were reexamined and revised based on scientific evidence that has emerged since the previous edition and observed shifts in clinical practice. New recommendations were formulated to reflect current clinical concerns and areas in which new research data have been generated. Results: Advances in our understanding of the pathophysiology of post-traumatic coagulopathy have supported improved management strategies, including evidence that early, individualised goal-directed treatment improves the outcome of severely injured patients. The overall organisation of the current guideline has been designed to reflect the clinical decision-making process along the patient pathway in an approximate temporal sequence. Recommendations are grouped behind the rationale for key decision points, which are patient-or problem-oriented rather than related to specific treatment modalities. While these recommendations provide guidance for the diagnosis and treatment of major bleeding and coagulopathy, emerging evidence supports the author group's belief that the greatest outcome improvement can be achieved through education and the establishment of and adherence to local clinical management algorithms. Conclusions: A multidisciplinary approach and adherence to evidence-based guidance are key to improving patient outcomes. If incorporated into local practice, these clinical practice guidelines have the potential to ensure a uniform standard of care across Europe and beyond and better outcomes for the severely bleeding trauma patient.

Relationship of thromboelastography and conventional clotting test values with severe bleeding in critically ill patients with coagulopathy: A prospective study

“…We include a mixed population with different diagnoses, although that is representative of our usual clinical practice. aPTT is not a targeted measure for bleeding control, as recently established by European guideline, and therefore, it should not be considered in this context. Last, the inclusion of platelet function tests could have improved the detection of severe bleeding.…”

Impact of a goal-directed factor-based coagulation management on thromboembolic events following major trauma

“…infections, volume overload, immunosuppression and kidney injury) [11][12][13][14] and it has been shown that a reduced transfusion requirement improved clinical outcomes including mortality [15,16]. Therefore, a factor-based, goal-directed coagulation management guided by viscoelastic point of care tests [2] has been proposed as a new approach of haemostatic resuscitation [1,7,[17][18][19]. This coagulation management was proven to decrease transfusion requirement with beneficial outcomes in trauma patients [1,7,17,18].…”

“…Therefore, a factor-based, goal-directed coagulation management guided by viscoelastic point of care tests [2] has been proposed as a new approach of haemostatic resuscitation [1,7,[17][18][19]. This coagulation management was proven to decrease transfusion requirement with beneficial outcomes in trauma patients [1,7,17,18]. The key element of the algorithm is the administration of coagulation factors according to an individualized goal-directed approach based on viscoelastic and laboratory assessment.…”

“…Since 2013 tranexamic acid was applied to patients already at the scene of injury before reaching the hospital, so our reported (in-hospital) incidence may well be underestimated. This haemostatic approach is a key element in the treatment of major trauma patients and recommended by the European Trauma Treatment Guidelines [1]. Frequency of thrombotic complications in trauma patients was reported in 1.1% up to 34.3% [25][26][27].…”

“…A goal-directed, factor-based coagulation management following major trauma is recommended as standard of care by the European Trauma Treatment Guidelines to treat and prevent trauma induced coagulopathy [1]. Such individualized coagulation management needs to be guided by viscoelastic testing and laboratory values [2,3] to meet patients' demands and is therefore more complex than traditional transfusion strategies of red blood cells (RBC), fresh frozen plasma (FFP) and platelet concentrates (PC) at fixed ratios [4].…”