- That adjunct tourniquet use to stop life-threatening bleeding from open extremity injuries in the pre-surgical setting 1B
- Normoventilation of trauma patients 1B.
- Hyperventilation in the presence of signs of imminent cerebral herniation. 2C
- In patients with severe TBI (GCS ≤8), recommends that a mean arterial pressure ≥80 mmHg be maintained. 1C
- Recommends an infusion of an inotropic agent in the presence of myocardial dysfunction. 1C
- 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
- Patients with ongoing haemodynamic instability despite adequate pelvic ring stabilisation receive early pre-peritoneal packing, angiographic
-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
- 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
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.
- Protocols for the management of bleeding patients consider administration of the first dose of tranexamic acid en route to the hospital. 2C
- 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
- 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
- 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
- They do not suggest that desmopressin be used routinely in the bleeding trauma patient. 2C
- Suggest the administration of PCC to mitigate life-threatening post-traumatic bleeding in patients treated with novel oral anticoagulants. 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-
- Early mechanical thromboprophylaxis with intermittent pneumatic compression (IPC). 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.