Management of bleeding following major trauma: an updated European guideline

Abstract

IntroductionEvidence-based recommendations are needed to guide the acute management of the bleeding trauma patient, which when implemented may improve patient outcomes.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 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.ResultsKey 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.ConclusionsThis guideline provides an evidence-based multidisciplinary approach to the management of critically injured bleeding trauma patients.

Major incident triage: Derivation and comparative analysis of the Modified Physiological Triage Tool (MPTT)

“…The JTTR does not record presence of a radial pulse as a variable, therefore for the purposes of prioritisation using START and Careflight, a surrogate systolic blood pressure of 90mmHg was taken to represent the presence of a radial pulse and absence of hypotension. 16,17 4 The primary outcome of the study was to derive the optimum ranges of each physiological parameter in isolation at predicting the need for life-saving intervention. The secondary outcome was to compare the performance of the Modified Physiological Triage Tool (MPTT), the combination of these independently derived parameters, with existing major incident triage tools.…”

Impact of crystalloids and colloids on coagulation cascade during trauma resuscitation-a literature review

“…Similarly to HTS, the evidence shows that HSD can improve haemodynamic parameters and reduce intracranial pressure [35]. Unfortunately, so far none of the studies demonstrated survival or outcome benefit associated with the use of HTS or HSD and further research is needed to clarify this issue [13,16,35,36].…”

“…The current evidence from meta-analyses showed an increased risk of death in trauma patients resuscitated with colloids [16,22]. However, a Cochrane review suggested no differences between crystalloids and colloids [27].…”

“…This is particularly true when faced with uncontrolled bleeding, for example, during the pre-hospital phase and when blood is not available. This approach has been augmented by the research, which showed that small boluses of crystalloids (250 mls) administrated in a controlled manner are beneficial during an active haemorrhage [16]. On the other hand, the fundamental doi: 10.7243/2052-6229-1-1 questions regarding the volume and type of the fluids infused remain still unanswered.…”

“…Even an updated Advanced Trauma Life Support (ATLS) manual finds it difficult to estimate the amount of intravenous fluids needed during resuscitation [9]. The most logical approach to administration of intravenous fluids appears to be based on patients' haemodynamic parameters and response to resuscitation [16]. Nevertheless, there is enough evidence that the administration of IVF during trauma can have detrimental effects on coagulation cascade.…”