LOADING AWESOME
The European guideline on management of major bleeding and coagulopathy following trauma: 4th Ed.
http://ccforum.biomedcentral.com/articles/10.1186/s13054-016-1265-x
First published in 2007; updated in 2010 & 2013. Expert opinion and clinical practice considered alongside RCT’s.
Dr. David Lyness
@Gas_Craic
SUMMARY OF RECOMMENDATIONS
- Patients should be transferred directly to an appropriate trauma treatment centre 1B
- That time elapsed between injury and bleeding control be minimised 1A
- That adjunct tourniquet use to stop life-threatening bleeding from open extremity injuries in the pre-surgical setting 1B
- That adjunct tourniquet use to stop life-threatening bleeding from open extremity injuries in the pre-surgical setting 1B
VENTILATION
- Avoidance of hypoxaemia. 1A
- Normoventilation of trauma patients 1B.
- Hyperventilation in the presence of signs of imminent cerebral herniation. 2C
- Normoventilation of trauma patients 1B.
- Hyperventilation in the presence of signs of imminent cerebral herniation. 2C
EXAMINATION & SCANS
- The physician should clinically assess the extent of traumatic haemorrhage using a combination of patient physiology,
anatomical injury pattern, mechanism of injury and the patient’s response to initial resuscitation. 1C
- That patients presenting with haemorrhagic shock and an identified source of bleeding undergo an immediate bleeding control
procedure unless initial resuscitation measures are successful. 1B
- Patients presenting with haemorrhagic shock and an unidentified source of bleeding should undergo immediate further investigation. 1B
- Early imaging (ultrasonography or contrast-enhanced CT) for the detection of free fluid in patients with suspected torso trauma. 1B
- Pt's with significant intra-thoracic/abdominal or retroperitoneal bleeding and haemodynamic instability undergo urgent intervention. 1A
- CT assessment for haemodynamically stable patients. 1B
- A low initial Hb be considered an indicator for severe bleeding associated with coagulopathy. 1B
- Recommend a target Hb of 7 to 9 g/dl. 1C
- Use of repeated Hb measurements as a laboratory marker for bleeding, as an initial Hb value in the normal range may mask bleeding. 1B
- Serum lactate and/or base deficit measurements as sensitive tests to estimate and monitor the extent of bleeding and shock 1B
- Recommends that routine practice include the early and repeated monitoring of coagulation, using either a traditional laboratory determination
[prothrombin time (PT), activated partial thromboplastin time (APTT) platelet counts and fibrinogen (1A) and/or a viscoelastic method (1C)
BLOOD PRESSURE
- Target systolic blood pressure of 80–90 mmHg until major bleeding has been stopped in the initial phase following trauma without brain injury. 1C
- In patients with severe TBI (GCS ≤8), recommends that a mean arterial pressure ≥80 mmHg be maintained. 1C
- In patients with severe TBI (GCS ≤8), recommends that a mean arterial pressure ≥80 mmHg be maintained. 1C
- In life-threatening hypotension, recommends administration of vasopressors in addition to fluids to maintain target arterial pressure. 1C
INOTROPES & FLUID THERAPY
- Recommends an infusion of an inotropic agent in the presence of myocardial dysfunction. 1C
- Recommends an infusion of an inotropic agent in the presence of myocardial dysfunction. 1C
- That fluid therapy using isotonic crystalloid solutions be initiated in the hypotensive bleeding trauma patient. 1A
- That excessive use of 0.9 % NaCl solution be avoided (hyperchloraemia) 2C
- Hypotonic solutions such as Ringer’s lactate be avoided in patients with severe head trauma 1C
-That the use of colloids be restricted due to the adverse effects on haemostats. 2C
- That excessive use of 0.9 % NaCl solution be avoided (hyperchloraemia) 2C
- Hypotonic solutions such as Ringer’s lactate be avoided in patients with severe head trauma 1C
-That the use of colloids be restricted due to the adverse effects on haemostats. 2C
HYPOTHERMIA
- Early application of measures to reduce heat loss and warm the hypothermic patient in order to achieve and maintain normothermia. 1C
DAMAGE CONTROL
- Damage control surgery should be employed in the severely injured patient presenting with deep haemorrhagic shock, signs of ongoing bleeding
and coagulopathy. 1B
-Other factors that should trigger a damage control approach are severe coagulopathy, hypothermia, acidosis, inaccessible major anatomic
injury, a need for time-consuming procedures or concomitant major injury outside the abdomen. 1C
- Primary definitive surgical management in the haemodynamically stable patient and in the absence of any of the factors above 1C
- Patients with pelvic ring disruption in haemorrhagic shock undergo immediate pelvic ring closure and stabilisation. 1B
- Patients with ongoing haemodynamic instability despite adequate pelvic ring stabilisation receive early pre-peritoneal packing, angiographic
- Patients with ongoing haemodynamic instability despite adequate pelvic ring stabilisation receive early pre-peritoneal packing, angiographic
embolisation and/or surgical bleeding control. 1B
HAEMOSTATIC AGENTS & BLOOD PRODUCTS
-Recommend the use of topical haemostatic agents in combination with other surgical measures or with packing for venous or
moderate arterial bleeding associated with parenchymal injuries. 1B
-Recommended that monitoring and measures to support coagulation be initiated immediately upon hospital admission. 1B
In the initial management of patients with expected massive haemorrhage, recommends one of the two following strategies:
-Plasma (FFP or pathogen-inactivated plasma) in a plasma–RBC ratio of at least 1:2 as needed. 1B
-Fibrinogen concentrate and RBC according to Hb level. 1C
-Plasma (FFP or pathogen-inactivated plasma) in a plasma–RBC ratio of at least 1:2 as needed. 1B
-Fibrinogen concentrate and RBC according to Hb level. 1C
- Specific pathophysiology associated with traumatic bleeding = increasingly recognised with evolving management strategies
- On hospital admission about one-third of all bleeding trauma patients already show signs of coagulopathy
- Significant increase in multiple organ failure & death compared to patients with similar injury patterns without coagulopathy
- On hospital admission about one-third of all bleeding trauma patients already show signs of coagulopathy
- Significant increase in multiple organ failure & death compared to patients with similar injury patterns without coagulopathy
Early acute coagulopathy associated with traumatic injury has recently been recognised as a multifactorial primary condition that results from a combination of bleeding-induced shock, tissue injury-related thrombin-thrombomodulin-complex generation and the activation of anticoagulant and fibrinolytic pathways
The severity of the coagulation disorder is influenced by environmental and therapeutic factors that result in, or at least contribute to, acidaemia, hypothermia, dilution, hypoperfusion and coagulation factor consumption
The coagulopathy is modified by trauma-related factors such as brain injury and individual patient-related factors that include age, genetic background, co-morbidities, inflammation and pre-medication, especially oral anticoagulants, and pre-hospital fluid administration.
The coagulopathy is modified by trauma-related factors such as brain injury and individual patient-related factors that include age, genetic background, co-morbidities, inflammation and pre-medication, especially oral anticoagulants, and pre-hospital fluid administration.
LOADING AWESOME
(figure from the article)
Avoid the triad of acidosis, coagulopathy and hypothermia
TXA
- Tranexamic acid be administered as early as possible to the trauma patient who is bleeding or at risk of significant haemorrhage at a loading dose of 1 g infused over 10 min, followed by an i.v. infusion of 1 g over 8 h. 1A
- Tranexamic acid should be administered to the bleeding trauma patient within 3 h after injury. 1B
- Protocols for the management of bleeding patients consider administration of the first dose of tranexamic acid en route to the hospital. 2C
- Protocols for the management of bleeding patients consider administration of the first dose of tranexamic acid en route to the hospital. 2C
COAG TESTING, PLASMA, PLTs & FIBRINOGEN
- Recommends that resuscitation measures be continued using a goal-directed strategy guided by standard laboratory coagulation values and/or
viscoelastic tests. 1C
- If a plasma-based coagulation resuscitation strategy is used, they recommend that plasma (FFP or pathogen-inactivated plasma) be administered to
maintain PT and APTT <1.5 times the normal control. 1C
- Recommends that plasma transfusion be avoided in patients without substantial bleeding. 1B
- If a concentrate-based strategy is used, they recommend treatment with fibrinogen concentrate or cryoprecipitate if significant bleeding is
accompanied by viscoelastic signs of a functional fibrinogen deficit or a plasma fibrinogen level of less than 1.5–2.0 g/l. 1C
- Suggests an initial fibrinogen supplementation of 3–4 g. This is equivalent to 15–20 single donor units of cryoprecipitate or 3–4 g fibrinogen
- Suggests an initial fibrinogen supplementation of 3–4 g. This is equivalent to 15–20 single donor units of cryoprecipitate or 3–4 g fibrinogen
concentrate. Repeat doses must be guided by viscoelastic monitoring and laboratory assessment of fibrinogen levels. 2C
- Recommend that platelets be administered to maintain a platelet count above 50. 1C
- Suggest maintenance of a platelet count above 100 in patients with ongoing bleeding and/or TBI. 2C
- If administered, they suggest an initial dose of four to eight single platelet units or one aphaeresis pack. 2C
- Suggest maintenance of a platelet count above 100 in patients with ongoing bleeding and/or TBI. 2C
- If administered, they suggest an initial dose of four to eight single platelet units or one aphaeresis pack. 2C
- Administer platelets in patients with substantial bleeding or intracranial haemorrhage who have been treated with antiplatelet agents. 2C
- Measure platelet function in patients treated or suspected of being treated with antiplatelet agents. 2C
- Suggest treatment with platelet concentrates if platelet dysfunction is documented in a patient with continued microvascular bleeding. 2C
- Measure platelet function in patients treated or suspected of being treated with antiplatelet agents. 2C
- Suggest treatment with platelet concentrates if platelet dysfunction is documented in a patient with continued microvascular bleeding. 2C
- Desmopressin (0.3 μg/kg) be administered in patients treated with platelet-inhibiting drugs or with von Willebrand disease. 2C
- They do not suggest that desmopressin be used routinely in the bleeding trauma patient. 2C
- They do not suggest that desmopressin be used routinely in the bleeding trauma patient. 2C
- Ionised calcium levels should be monitored and maintained within the normal range during massive transfusion. 1C
PROTHROMBIN COMPLEX
- Early use of prothrombin complex concentrate (PCC) for the emergency reversal of vitamin K-dependent oral anticoagulants. 1A
- Suggest the administration of PCC to mitigate life-threatening post-traumatic bleeding in patients treated with novel oral anticoagulants. 2c
- Suggest the administration of PCC to mitigate life-threatening post-traumatic bleeding in patients treated with novel oral anticoagulants. 2c
- Provided that fibrinogen levels are normal, suggests that PCC or plasma be administered in the bleeding patient based on evidence of delayed
coagulation initiation using viscoelastic monitoring. 2C
- Suggests the measurement of plasma levels of oral anti-factor Xa agents such as rivaroxaban, apixaban or edoxaban in patients treated or
suspected of being treated with one of these agents. 2C
If measurement is not possible or available, suggests that advice from an expert haematologist be sought. 2C
If bleeding is life-threatening, they suggest treatment with TXA 15 mg/kg (or 1 g) intravenously and high-dose (25-50 U/kg) PCC/aPCC until specific antidotes are available. 2C
If measurement is not possible or available, suggests that advice from an expert haematologist be sought. 2C
If bleeding is life-threatening, they suggest treatment with TXA 15 mg/kg (or 1 g) intravenously and high-dose (25-50 U/kg) PCC/aPCC until specific antidotes are available. 2C
DOAC - DABIGITRAN
- Measurement of dabigatran plasma levels should be performed in patients treated or suspected of being treated with dabigatran. 2C
- If measurement is not possible or available, suggests thrombin time and APTT to allow a qualitative estimation of the presence of dabigatran. 2C
- If bleeding is life-threatening, recommends treatment with idarucizumab (5 g intravenously), or, if unavailable, suggests treatment with high-
dose (25–50 U/kg) PCC/aPCC, in both cases combined with TXA 15 mg/kg (or 1 g) intravenously. 2C
- Off-label use of rFVIIa be considered only if major bleeding and traumatic coagulopathy persist despite all other attempts
to control bleeding and best-practice use of conventional haemostatic measures. 2C
THROMBOPROPHYLAXIS POST-CONTROL
- Recommends pharmacological thromboprophylaxis within 24 h after bleeding has been controlled. 1B
- Early mechanical thromboprophylaxis with intermittent pneumatic compression (IPC). 1C
- Early mechanical thromboprophylaxis with intermittent pneumatic compression (IPC). 1C
- Early mechanical thromboprophylaxis with anti-embolic stockings. 2C
- They do not recommend the routine use of inferior vena cava filters as thromboprophylaxis. 1C
- Encourages use of a restricted volume replacement strategy during initial resuscitation.
- Best-practice use of blood products during further resuscitation is evolving and should be based on goal-directed strategy.
- The ID and management of pt’s with anticoagulants on board = difficult despite experience and awareness of practitioners.
- Asks that local quality and safety systems be in place to assess key measures of bleeding control and outcome.
- A multidisciplinary approach and adherence to evidence-based guidance are key to improving patient outcomes.
Critical Care 2016 - 20:100
Access the 55 page guideline
here to see the full evidence
base and discussion &
rationale of each of the recommendations.
This infogram aims only to be a summary of the
key recommendations.
1A - Strong recommendation, high-quality evidence
1B - Strong recommendation, moderate-quality evidence
1C - Strong recommendation, low-quality or very low-quality evidence
2A - Weak recommendation, high-quality evidence
2B - Weak recommendation, moderate-quality evidence
2C - Weak recommendation, low-quality or very low-quality evidence
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