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

Rolf Rossaint, Arash Afshari, Bertil Bouillon, Vladimir Cerny, Diana Cimpoesu, Nicola Curry, Jacques Duranteau, Daniela Filipescu, Oliver Grottke, Lars Grønlykke, Anatole Harrois, Beverley J Hunt, Alexander Kaserer, Radko Komadina, Mikkel Herold Madsen, Marc Maegele, Lidia Mora, Louis Riddez, Carolina S Romero, Charles-Marc Samama, Jean-Louis Vincent, Sebastian Wiberg, Donat R Spahn, Rolf Rossaint, Arash Afshari, Bertil Bouillon, Vladimir Cerny, Diana Cimpoesu, Nicola Curry, Jacques Duranteau, Daniela Filipescu, Oliver Grottke, Lars Grønlykke, Anatole Harrois, Beverley J Hunt, Alexander Kaserer, Radko Komadina, Mikkel Herold Madsen, Marc Maegele, Lidia Mora, Louis Riddez, Carolina S Romero, Charles-Marc Samama, Jean-Louis Vincent, Sebastian Wiberg, Donat R Spahn

Abstract

Background: Severe trauma represents a major global public health burden and the management of post-traumatic bleeding continues to challenge healthcare systems around the world. Post-traumatic bleeding and associated traumatic coagulopathy remain leading causes of potentially preventable multiorgan failure and death if not diagnosed and managed in an appropriate and timely manner. This sixth edition of the European guideline on the management of major bleeding and coagulopathy following traumatic injury aims to advise clinicians who care for the bleeding trauma patient during the initial diagnostic and therapeutic phases of patient management.

Methods: The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma included representatives from six European professional societies and convened to assess and update the previous version of this guideline using a structured, evidence-based consensus approach. Structured literature searches covered the period since the last edition of the guideline, but considered evidence cited previously. The format of this edition has been adjusted to reflect the trend towards concise guideline documents that cite only the highest-quality studies and most relevant literature rather than attempting to provide a comprehensive literature review to accompany each recommendation.

Results: This guideline comprises 39 clinical practice recommendations that follow an approximate temporal path for management of the bleeding trauma patient, with recommendations grouped behind key decision points. While approximately one-third of patients who have experienced severe trauma arrive in hospital in a coagulopathic state, a systematic diagnostic and therapeutic approach has been shown to reduce the number of preventable deaths attributable to traumatic injury.

Conclusion: A multidisciplinary approach and adherence to evidence-based guidelines are pillars of best practice in the management of severely injured trauma patients. Further improvement in outcomes will be achieved by optimising and standardising trauma care in line with the available evidence across Europe and beyond.

Keywords: Diagnostics; Emergency medicine; Haemostasis; Major bleeding; Management; Practice guideline; Trauma; Traumatic coagulopathy.

Conflict of interest statement

RR: 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 received research grand funding from the German Research Foundation. AA has no competing interests to declare. BB has no competing interests to declare. VC has no competing interests to declare. DC: In the past 5 years, DC has received funding from the European Union Competitiveness Operational Program; UEFISCDI (Unitatea Executiva Pentru Finantarea Invatamantului Superior a Cercetarii Dezvoltarii si Inovarii), the Romanian National Plan for Research, Development, and Innovation; NATO-SPS (North Atlantic Treaty Organisation—Science for Peace and Security); Erasmus+ First Aid Improve Survival (TIRAMISU)" and COST Action CA19137. NC: In the last 5 years, NC has received honoraria for consulting from LFB, Bayer and Sobi and institutional research grant support from CSL Behring and Sobi. JD: In the last 5 years, JD has received honoraria for symposium lectures from Octapharma and LFB Biomédicaments. DF: In the past 5 years, DF has received honoraria for lecturing from the University of Continuing Education, Department for Health Sciences and Medicine and Research, Krems, Donau University & Eurasia Heart Foundation, Austria, the 2019 International Congress of Cardiothoracic and Vascular Anesthesia & Asian Society of Cardiothoracic Anesthesia Organizing Committee, the American Society of Anesthesiologists, and the Instrumentation Laboratory Company (Werfen). DF received institutional support from Vifor Pharma Romania SRL. DF is the deputy chair of the Romanian Anaemia Working Group and chair of the Romanian Patient Blood Management implementation group. OG: In the past 5 years, OG has received research funding from Astra Zeneca (Hamburg, Germany), Alveron (Amsterdam, The Netherlands), Bayer AG (Wuppertal, Germany), Boehringer Ingelheim (Ingelheim, Germany), CSL Behring (Marburg, Germany), Octapharma (Lachen, Switzerland), Portola (San Francisco, California), Werfen (Munich, Germany) and the German Research Foundation (DFG). He has also received honoraria for lectures and consultancy from Baxalta (Unterschleißheim, Germany), Bayer AG (Wuppertal, Germany), Boehringer Ingelheim, CSL Behring (Marburg, Germany), Ferring (Kiel, Germany), Octapharma (Lachen, Switzerland), Pfizer (Berlin, Germany), Takeda (Zurich, Switzerland), Portola (San Francisco, California), Sanofi (Berlin, Germany) and Werfen (Munich, Germany). LG has no competing interests to declare. AH: In the past 5 years, AH has received honoraria for consulting or lecturing from LFB Biomédicaments, Edwards Lifesciences, AOP Orphans Pharmaceuticals and Mindray. BJH has no competing interests to declare. AK: In the last 5 years, AK has received honoraria for lecturing from Bayer AG, Zürich, Switzerland. RK: In the past 5 years, RK has received honoraria for consulting or lecturing from CSL Behring. MHM: In the past 5 years, MHM has received institutional research grant support from the Department of Anaesthesia, Nordsjaellands Hospital, University of Copenhagen, Hilleroed, Denmark. MM: In the past 5 years, MM has received honoraria and support for speaker bureaus, lectures, advisory boards, conference travels and research activities from Abbott Inc, Alexion Pharma, AstraZeneca, Bayer, Biotest, CSL Behring, IL Werfen/Instrumentation Laboratories and LFB Biomédicaments. LM has no competing interests to declare. LR has no competing interests to declare. CSR has no competing interests to declare. CMS: In the last five years, CMS’ department has received an honorarium from Norgine and three grants from i-SEP, Octapharma and Sanofi India. From 2019 to 2022 CMS served as chair of NATA, with several contacts with industry and some grants to NATA from CSL Behring, Hemosonics, i-SEP, Masimo, Medtronic, Nordic pharma Octapharma, Pharmacosmos, Sysmex, Vifor, Werfen (no personal benefit). JLV has no competing interests to declare. SW has no competing interests to declare. DRS: In the past 5 years, DRS’s academic department has received grant support from the Swiss National Science Foundation, Berne, Switzerland, the Swiss Society of Anesthesiology and Perioperative Medicine (SSAPM), Berne, Switzerland, the Swiss Foundation for Anesthesia Research, Zurich, Switzerland, Vifor SA, Villars-sur-Glâne, Switzerland and Vifor (International) AG, St. Gallen, 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/travel support for consulting or lecturing from: Alliance Rouge, Bern, Switzerland, Danube University of Krems, Austria, European Society of Anesthesiology and Intensive Care, Brussels, BE, Korean Society for Patient Blood Management, Seoul, Korea, Korean Society of Anesthesiologists, Seoul, Korea, Network for the Advancement of Patient Blood Management, Haemostasis and Thrombosis, Paris, France, Alexion Pharmaceuticals Inc., Boston, MA, AstraZeneca AG, Baar, Switzerland, Bayer AG, Zürich, Switzerland, B. Braun Melsungen AG, Melsungen, Germany, CSL Behring GmbH, Hattersheim am Main, Germany and Berne, Switzerland, Celgene International II Sàrl, Couvet, Switzerland, Daiichi Sankyo AG, Thalwil, Switzerland, Haemonetics, Braintree, MA, USA, Instrumentation Laboratory (Werfen), Bedford, MA, USA, LFB Biomédicaments, Courtaboeuf Cedex, France, Merck Sharp & Dohme, Kenilworth, New Jersey, USA, Novo Nordisk Health Care AG, Zurich, Switzerland, PAION Deutschland GmbH, Aachen, Germany, Pharmacosmos A/S, Holbaek, Denmark, Pfizer AG, Zürich, Switzerland, Pierre Fabre Pharma, Alschwil, Switzerland, Portola Schweiz GmbH, Aarau, Switzerland, Roche Diagnostics International Ltd, Reinach, Switzerland, Sarstedt AG & Co., Sevelen, Switzerland and Nümbrecht, Germany, Shire Switzerland GmbH, Zug, Switzerland, Takeda, Glattpark, Switzerland, Tem International GmbH, Munich, Germany, Vifor Pharma, Munich, Germany, Neuilly sur Seine, France and Villars-sur-Glâne, Switzerland, Vifor (International) AG, St. Gallen, Switzerland, Zuellig Pharma Holdings, Singapore, Singapore.

© 2023. The Author(s).

Figures

Fig. 1
Fig. 1
Summary of treatment modalities for the bleeding trauma patient included in this guideline. APTT Activated partial thromboplastin time, CT Computed tomography, FFP Fresh frozen plasma, GCS Glasgow coma scale, Hb Haemoglobin, Hct Haematocrit, INR International normalised ratio, LMWH Low molecular weight heparin, MAP Mean arterial pressure, PCC Prothrombin complex concentrate, PT Prothrombin time, pRBC Packed red blood cells, REBOA Resuscitative endovascular balloon occlusion of the aorta, TBI Traumatic brain injury
Fig. 1
Fig. 1
Summary of treatment modalities for the bleeding trauma patient included in this guideline. APTT Activated partial thromboplastin time, CT Computed tomography, FFP Fresh frozen plasma, GCS Glasgow coma scale, Hb Haemoglobin, Hct Haematocrit, INR International normalised ratio, LMWH Low molecular weight heparin, MAP Mean arterial pressure, PCC Prothrombin complex concentrate, PT Prothrombin time, pRBC Packed red blood cells, REBOA Resuscitative endovascular balloon occlusion of the aorta, TBI Traumatic brain injury
Fig. 1
Fig. 1
Summary of treatment modalities for the bleeding trauma patient included in this guideline. APTT Activated partial thromboplastin time, CT Computed tomography, FFP Fresh frozen plasma, GCS Glasgow coma scale, Hb Haemoglobin, Hct Haematocrit, INR International normalised ratio, LMWH Low molecular weight heparin, MAP Mean arterial pressure, PCC Prothrombin complex concentrate, PT Prothrombin time, pRBC Packed red blood cells, REBOA Resuscitative endovascular balloon occlusion of the aorta, TBI Traumatic brain injury

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