The European guideline on management of major bleeding and coagulopathy following trauma: fifth edition

Donat R Spahn, Bertil Bouillon, Vladimir Cerny, Jacques Duranteau, Daniela Filipescu, Beverley J Hunt, Radko Komadina, Marc Maegele, Giuseppe Nardi, Louis Riddez, Charles-Marc Samama, Jean-Louis Vincent, Rolf Rossaint, Donat R Spahn, Bertil Bouillon, Vladimir Cerny, Jacques Duranteau, Daniela Filipescu, Beverley J Hunt, Radko Komadina, Marc Maegele, Giuseppe Nardi, Louis Riddez, Charles-Marc Samama, Jean-Louis Vincent, Rolf Rossaint

Abstract

Background: Severe traumatic injury continues to present challenges to healthcare systems around the world, and post-traumatic bleeding remains a leading cause of potentially preventable death among injured patients. Now in its fifth edition, this document aims to provide guidance on the management of major bleeding and coagulopathy following traumatic injury and encourages adaptation of the guiding principles described here to individual institutional circumstances and resources.

Methods: The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma was founded in 2004, and the current author group included representatives of six relevant European professional societies. The group applied a structured, evidence-based consensus approach to address scientific queries that served as the basis for each recommendation and supporting rationale. Expert opinion and current clinical practice were also considered, particularly in areas in which randomised clinical trials have not or cannot be performed. Existing recommendations were re-examined and revised based on scientific evidence that has emerged since the previous edition and observed shifts in clinical practice. New recommendations were formulated to reflect current clinical concerns and areas in which new research data have been generated.

Results: Advances in our understanding of the pathophysiology of post-traumatic coagulopathy have supported improved management strategies, including evidence that early, individualised goal-directed treatment improves the outcome of severely injured patients. The overall organisation of the current guideline has been designed to reflect the clinical decision-making process along the patient pathway in an approximate temporal sequence. Recommendations are grouped behind the rationale for key decision points, which are patient- or problem-oriented rather than related to specific treatment modalities. While these recommendations provide guidance for the diagnosis and treatment of major bleeding and coagulopathy, emerging evidence supports the author group's belief that the greatest outcome improvement can be achieved through education and the establishment of and adherence to local clinical management algorithms.

Conclusions: A multidisciplinary approach and adherence to evidence-based guidance are key to improving patient outcomes. If incorporated into local practice, these clinical practice guidelines have the potential to ensure a uniform standard of care across Europe and beyond and better outcomes for the severely bleeding trauma patient.

Keywords: Coagulopathy; Emergency medicine; Haemostasis; Practice guideline; Trauma.

Conflict of interest statement

Authors’ information

RR serves as chair of the Advanced Bleeding Care in Trauma (ABC-T) European Medical Education Initiative.
DRS serves as co-chair of the ABC-T European Medical Education Initiative.
BB is a member of the ABC-T European Medical Education Initiative faculty.
VC is a member of the ABC-T European Medical Education Initiative faculty.
JD represented the European Society of Intensive Care Medicine (ESICM) on the ABC-T Task Force.
DF represented the European Society of Anaesthesiology (ESA) on the ABC-T Task Force.
MM represented the European Shock Society (ESS) on the ABC-T Task Force.
GN is a member of the ABC-T European Medical Education Initiative faculty.
BJH is a member of the ABC-T European Medical Education Initiative faculty.
RK represented the European Society of Trauma and Emergency Surgery (ESTES) on the ABC-T Task Force.
LR represented the European Society for Emergency Medicine (EuSEM) on the ABC-T Task Force.
CMS represented the Network for the Advancement of Patient Blood Management, Haemostasis and Thrombosis (NATA) on the ABC-T Task Force.
JLV is a member of the ABC-T European Medical Education Initiative faculty.

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

In the past 5 years, DRS’s academic department has received grant support from the Swiss National Science Foundation, Berne, Switzerland, the Ministry of Health (Gesundheitsdirektion) of the Canton of Zurich, Switzerland for Highly Specialized Medicine, the Swiss Society of Anesthesiology and Reanimation (SGAR), Berne, Switzerland, the Swiss Foundation for Anesthesia Research, Zurich, Switzerland, CSL Behring, Berne, Switzerland, Vifor SA, Villars-sur-Glâne, Switzerland. DRS is co-chair of the ABC-Trauma Faculty, sponsored by unrestricted educational grants from Novo Nordisk Health Care AG, Zurich, Switzerland, CSL Behring GmbH, Marburg, Germany, LFB Biomédicaments, Courtaboeuf Cedex, France and Octapharma AG, Lachen, Switzerland. DRS received honoraria or travel support for consulting or lecturing from: Danube University of Krems, Austria, US Department of Defense, Washington, USA, European Society of Anesthesiology, Brussels, BE, Korea, Korean Society for Patient Blood Management, Seoul, Korea, Korean Society of Anesthesiologists, Seoul, Baxter AG, Volketswil, Switzerland, Baxter S.p.A., Roma, Italy, Bayer AG, Zürich, Switzerland, Bayer Pharma AG, Berlin, Germany, B. Braun Melsungen AG, Melsungen, Germany, Boehringer Ingelheim GmbH, Basel, Switzerland, Bristol-Myers-Squibb, Rueil-Malmaison Cedex, France and Baar, Switzerland, CSL Behring GmbH, Hattersheim am Main, Germany and Berne, Switzerland, Celgene International II Sàrl, Couvet, Switzerland, Curacyte AG, Munich, Germany, Daiichi Sankyo AG, Thalwil, Switzerland, GlaxoSmithKline GmbH & Co. KG, Hamburg, Germany, Haemonetics, Braintree, MA, USA, Instrumentation Laboratory (Werfen), Bedford, MA, USA, LFB Biomédicaments, Courtaboeuf Cedex, France, Merck Sharp & Dohme, Kenilworth, New Jersey, USA, Octapharma AG, Lachen, Switzerland, Organon AG, Pfäffikon/SZ, Switzerland, PAION Deutschland GmbH, Aachen, Germany, Pharmacosmos A/S, Holbaek, Denmark, Photonics Healthcare B.V., Utrecht, Netherlands, Roche Diagnostics International Ltd., Reinach, Switzerland, Roche Pharma AG, Reinach, Switzerland, Sarstedt AG & Co., Sevelen, Switzerland and Nümbrecht, Germany Schering-Plough International, Inc., Kenilworth, New Jersey, USA, Tem International GmbH, Munich, Germany, Verum Diagnostica GmbH, Munich, Germany, Vifor Pharma, Munich, Germany, Vienna, Austria and Villars-sur-Glâne, Switzerland, Vifor (International) AG, St. Gallen.
BB has no competing interests to declare.
In the past 5 years, VC has received honoraria for consulting or lecturing from CSL Behring, AbbVie, BBraun, Bard. VC reports research grant funding from the Czech Health Research Council, Czech Republic, and the Charles University Faculty of Medicine in Hradec Kralove, Czech Republic. VC has received institutional support from the Charles University Faculty of Medicine in Hradec Kralove, Czech Republic, the University Hospital Hradec Kralove, Czech Republic and Masaryk Hospital Usti nad Labem, Czech Republic.
In the past 5 years, JD has received honoraria for lecturing from LFB Biomédicaments.
In the past 5 years, DF has received honoraria for lecturing from the following companies and organisations: Romanian Society of Cardiology, MedLife Health System and Danube University of Krems, Austria. DF has received institutional support from Vifor Pharma, Siramed SRL and Synttergy Consult SRL.
In the past 5 years, BJH has received research grant funding from CSL Behring.
In the past 5 years, RK has received honoraria for lecturing from CSL Behring.
In the past 5 years, MM has received honoraria for consulting or lecturing from Astra Zeneca, Bayer, Biotest, CSL Behring, IL Werfen/TEM International, LFB Biomedicaments France and has received research grant funding from CSL Behring.
In the past 5 years, GN has received honoraria for lecturing from CSL Behring.
LR has no competing interests to declare.
In the past 5 years, CMS has received honoraria for consulting or lecturing from Aspen, Daiichi-Sankyo, Medtronic, Roche, BMS, Pfizer, Bayer, Stago, Siemens, Octapharma, LFB Biomédicaments and has received research grant funding from Haemonetics.
JLV has no competing interests to declare.
In the past 5 years, RR has received honoraria for consulting or lecturing from CSL Behring, Boehringer Ingelheim and Fresenius. In fields related to this work RR or his co-workers received research grant funding from DFG, Bayer, Biotest, Boehringer Ingelheim, CSL Behring, Novo Nordisk and Nycomed.

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Figures

**Fig. 1**
Schematic drawing of the factors, including those that are preexisting as well as those related to both trauma and resuscitation measures, that contribute to traumatic coagulopathy. Adapted from [, , –32, 38]

**Fig. 2**
a Summary of treatment modalities for the bleeding trauma patients included in this guideline. CT, computed tomography; FAST, focused assessment with sonography in trauma; Hb, haemoglobin; PT, prothrombin time. b Summary of treatment modalities for the bleeding trauma patients included in this guideline. FFP, fresh frozen plasma; Hb, haemoglobin; RBC, red blood cells; TBI, traumatic brain injury; TXA, tranexamic acid. c Summary of treatment modalities for the bleeding trauma patients included in this guideline. APA, antiplatelet agent; APTT, activated partial thromboplastin time; FFP, fresh frozen plasma; FXIII, factor XIII; PCC, prothrombin complex concentrate; PT, prothrombin time; rFVIIa, recombinant activated coagulation factor VII; TBI, traumatic brain injury; TXA, tranexamic acid

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The European guideline on management of major bleeding and coagulopathy following trauma: fifth edition

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