Management of bleeding following major trauma: a European guideline

Donat R Spahn¹ , Vladimir Cerny² , Timothy J Coats³ , Jacques Duranteau⁴ , Enrique Fernández-Mondéjar⁵ , Giovanni Gordini⁶ , Philip F Stahel⁷ , Beverley J Hunt⁸ , Radko Komadina⁹ , Edmund Neugebauer¹⁰ , Yves Ozier¹¹ , Louis Riddez¹² , Arthur Schultz¹³ , Jean-Louis Vincent¹⁴ and Rolf Rossaint¹⁵

¹Department of Anesthesiology, University Hospital Zurich, Rämistrasse 100, 8091 Zurich, Switzerland

²Charles 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

³Leicester Royal Infirmary, Accident and Emergency Department, Infirmary Square, Leicester LE1 5WW, UK

⁴Department of Anaesthesia and Intensive Care, University of Paris XI Faculté de Médecine Paris-Sud, 63 rue Gabriel Péri, 94276 Le Kremlin-Bicêtre, France

⁵Department of Emergency and Critical Care Medicine, University Hospital Virgen de las Nieves, ctra de Jaén s/n, 18013 Granada, Spain

⁶Department of Anaesthesia and Intensive Care, Ospedale Maggiore, Largo Nigrisoli 2, 40100 Bologna, Italy

⁷Department of Orthopaedic Surgery, Denver Health Medical Center, University of Colorado Medical School, 777 Bannock Street, Denver, CO 80204, USA

⁸Departments of Haematology, Pathology and Rheumatology, Guy's & St Thomas' Foundation Trust, Lambeth Palace Road, London SE1 7EH, UK

⁹Department of Traumatology, General and Teaching Hospital Celje, 3000 Celje, Slovenia

¹⁰Institute for Research in Operative Medicine, University of Witten/Herdecke, Ostmerheimerstrasse 200, 51109 Köln (Merheim), Germany

¹¹Department of Anaesthesia and Intensive Care, Université René Descartes Paris 5, AP-HP, Hopital Cochin, 27 rue du Fbg Saint-Jacques, 75014 Paris, France

¹²Department of Surgery and Trauma, Karolinska University Hospital, 171 76 Solna, Sweden

¹³Ludwig-Boltzmann-Institute for Experimental and Clinical Traumatology, Donaueschingenstrasse 13, 1200 Vienna, Austria

¹⁴Department of Intensive Care, Erasme Hospital, University of Brussels, Belgium, route de Lennik 808, 1070 Brussels, Belgium

¹⁵Department of Anaesthesiology, University Hospital Aachen, Pauwelsstraße 30, 52074 Aachen, Germany

author email corresponding author email

Critical Care 2007, 11:R17doi:10.1186/cc5686


Published:	13 February 2007

See related commentary by Minei, http://ccforum.com/content/11/2/128

Abstract

Introduction

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.

Methods

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.

Results

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.

Conclusion

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.