Scandinavian Guidelines — “The Massively Bleeding Patient”

Abstract

16C. Gaarder et al. the prehospital careprovider with amoreorless obvious mechanismo fi njury,c omplaintsa nd symptoms, and with many uncontrolled factors making both diagnosis and triage achallenge.Vo lume loading results in adecrease in haemoglobin and clotting factors. Furthermore, the relative expansion with 500 ml of isotonic crystalloid is greater in as hocked person than in ah ealthy individual. The optimal volume of intravenous fluid to administer is abalance between avoiding hypovolaemia and not increasing systolic blood pressure(SBP) causing disruption of clots and further bleeding. To what extent this is moret han at heoretical worry in patients with blunt trauma, is not well documented. Several animal models of penetrating injury,h owever,h ave documented the relationship between increasing blood pressure, increased bleeding and fatal outcome.AS BP <90m mH gi su sed extensively to assess volume status in trauma patients, both for triage, treatment and study protocols. How well aSBP <90 mm Hg defines the presence of uncontrolled bleeding, the need for intravenous fluid resuscitation and later surgical interventions is still not clear.T herei s also some evidence to support the use of only manual SBP for pre-hospital, or hospital, triage decisions (1).In EMS (Emergency Medical Services) systems wherep re-hospital fluid therapy is used, the incidence of hypotension at hospital admission is lower than 10% and the need for immediate haemostatic surgery is low (5). Recent publications have reinforced the impression that fluid resuscitation and blood transfusion in the Emergency Department still aree ssential elements of early management in most critically injured patients. Hence, providing the same therapy earlier,i fn ot exaggerated, seems logical. A major concern with prehospital fluid therapy is that infusing cold fluids will cause hypothermia in the patients, afactor known to reduce clotting activity.Patients with severeT BI (traumatic brain injury) do not tolerate even short periods of hypotension. Hence, theu se of volume therapy to counteract hypovolaemia and hypotension is considered standard treatment by most authors. The discussion has been focused moreonwhat systolic blood pressuretoaim for and what fluid to use. RECOMMENDATIONS

A retrospective quality assessment of pre-hospital emergency medical documentation in motor vehicle accidents in south-eastern Norway

“…In Scandinavia, great efforts have been made in recent years to improve early trauma care. Guidelines have been developed for pre-hospital airway management [4], for massive bleeding in trauma patients [5], and for uniform reporting of data on major trauma [6]. Still, an ongoing debate over the required skills levels, procedures, methodology, and variables to be reported by EMS delay the implementation of uniform agreements [7-10].…”

Can the Viscoelastic Parameter α-Angle Distinguish Fibrinogen from Platelet Deficiency and Guide Fibrinogen Supplementation?

“…6,[8][9][10][11][12][33][34][35][36]38,[40][41][42][43][44][45][46][47][48] In these algorithms, the threshold values of the TEG® mono-analysis α-angle and MA trigger the recommendation for the administration of different hemostatic therapies (Table 1). These thresholds, the specific therapies and the recommended doses, vary between publications, and the differences are especially pronounced for algorithms concerning the management of bleeding in trauma patients.…”

Hemostatic Effectiveness of Fibrin Pad After Partial Nephrectomy in Swine

“…When these conventional measures are ineffective or impractical, adjunctive hemostasis techniques and products are typically utilized. These include topical absorbable hemostats (TAH), such as oxidized regenerated cellulose, gelatin, or collagen [17] and active hemostats, such as topical thrombin or fibrin sealants [18,19]. These products have proven most efficacious in controlling slowly bleeding foci, diffuse oozing, bleeding from needle puncture sites, and diffuse parenchymal organ hemorrhage.…”