Management of bleeding following major trauma: a European guideline
1 Department of Anesthesiology, University Hospital Zurich, Rämistrasse 100, 8091 Zurich, Switzerland
2 Charles University in Prague, Faculty of Medicine in Hradec Králové, Department of Anaesthesiology and Intensive Care Medicine, University Hospital Hradec Králové, Sokolska 581, 50005 Hradec Králové, Czech Republic
3 Leicester Royal Infirmary, Accident and Emergency Department, Infirmary Square, Leicester LE1 5WW, UK
4 Department of Anaesthesia and Intensive Care, University of Paris XI Faculté de Médecine Paris-Sud, 63 rue Gabriel Péri, 94276 Le Kremlin-Bicêtre, France
5 Department of Emergency and Critical Care Medicine, University Hospital Virgen de las Nieves, ctra de Jaén s/n, 18013 Granada, Spain
6 Department of Anaesthesia and Intensive Care, Ospedale Maggiore, Largo Nigrisoli 2, 40100 Bologna, Italy
7 Department of Orthopaedic Surgery, Denver Health Medical Center, University of Colorado Medical School, 777 Bannock Street, Denver, CO 80204, USA
8 Departments of Haematology, Pathology and Rheumatology, Guy's & St Thomas' Foundation Trust, Lambeth Palace Road, London SE1 7EH, UK
9 Department of Traumatology, General and Teaching Hospital Celje, 3000 Celje, Slovenia
10 Institute for Research in Operative Medicine, University of Witten/Herdecke, Ostmerheimerstrasse 200, 51109 Köln (Merheim), Germany
11 Department of Anaesthesia and Intensive Care, Université René Descartes Paris 5, AP-HP, Hopital Cochin, 27 rue du Fbg Saint-Jacques, 75014 Paris, France
12 Department of Surgery and Trauma, Karolinska University Hospital, 171 76 Solna, Sweden
13 Ludwig-Boltzmann-Institute for Experimental and Clinical Traumatology, Donaueschingenstrasse 13, 1200 Vienna, Austria
14 Department of Intensive Care, Erasme Hospital, University of Brussels, Belgium, route de Lennik 808, 1070 Brussels, Belgium
15 Department of Anaesthesiology, University Hospital Aachen, Pauwelsstraße 30, 52074 Aachen, Germany
Critical Care 2007, 11:R17 doi:10.1186/cc5686
See related commentary by Minei, http://ccforum.com/content/11/2/128Published: 13 February 2007
Evidence-based recommendations can be made with respect to many aspects of the acute management of the bleeding trauma patient, which when implemented may lead to improved patient outcomes.
The multidisciplinary Task Force for Advanced Bleeding Care in Trauma was formed in 2005 with the aim of developing guidelines for the management of bleeding following severe injury. Recommendations were formulated using a nominal group process and the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) hierarchy of evidence and were based on a systematic review of published literature.
Key recommendations include the following: The time elapsed between injury and operation should be minimised for patients in need of urgent surgical bleeding control, and patients presenting with haemorrhagic shock and an identified source of bleeding should undergo immediate surgical bleeding control unless initial resuscitation measures are successful. A damage control surgical approach is essential in the severely injured patient. Pelvic ring disruptions should be closed and stabilised, followed by appropriate angiographic embolisation or surgical bleeding control, including packing. Patients presenting with haemorrhagic shock and an unidentified source of bleeding should undergo immediate further assessment as appropriate using focused sonography, computed tomography, serum lactate, and/or base deficit measurements. This guideline also reviews appropriate physiological targets and suggested use and dosing of blood products, pharmacological agents, and coagulation factor replacement in the bleeding trauma patient.
A multidisciplinary approach to the management of the bleeding trauma patient will help create circumstances in which optimal care can be provided. By their very nature, these guidelines reflect the current state-of-the-art and will need to be updated and revised as important new evidence becomes available.