Guideline sources The following summarized guidelines for the evaluation and management of traumatic hemorrhage are prepared by our editorial team based on guidelines from the Pediatric Traumatic Hemorrhagic Shock Consensus Conference (PTHSCC 2023), the Pan-European Multidisciplinary Task Force for Advanced Bleeding Care in Trauma (ABC-T 2023; 2019), the British Society for Haematology (BSH 2022; 2018), the French Society of Emergency Medicine (SFMU/SFAR 2022), the European Society of Intensive Care Medicine (ESICM 2021), the Eastern Association for the Surgery of Trauma (EAST 2020; 2017; 2011), the Society of Interventional Radiology (SIR 2020), the World Society of Emergency Surgery (WSES 2017), and the American College of Surgeons (ACS 2014). 1 2 3 4 5 6 7 8 9 10 11 12 13 Guidelines 1. Diagnostic investigations Initial assessment: assess the extent of traumatic hemorrhage clinically using a combination of patient physiology, anatomical injury pattern, mechanism of injury, and the patient response to https://web.pathway.md/diseases/recfvXYVmcdhWmw2B 1/11 6/24/23, 4:09 PM Traumatic hemorrhage Pathway initial resuscitation. B Show 2 more Laboratory testing: As per ABC-T 2023 guidelines: Obtain repeated Hgb and/or hematocrit measurements as a laboratory marker for bleeding, as an initial value in the normal range may mask early-phase bleeding. B Obtain blood lactate as a sensitive test to estimate and monitor the extent of bleeding and tissue hypoperfusion. Consider assessing base deficit as a suitable alternative in the absence of lactate measurements. B As per WSES 2017 guidelines, measure serum lactate and base deficit to estimate the extent of traumatic-hemorrhagic shock, and to monitor response to resuscitation. B Coagulation and viscoelastic testing: As per BSH 2022 guidelines, consider obtaining viscoelastic hemostatic assays to guide transfusion therapy in patients with traumatic hemorrhage, taking into account the costs and benefits of these tests and ensuring policies are in place to maintain these devices on a daily basis. B As per ESICM 2021 guidelines, consider obtaining either viscoelastic testing or conventional coagulation testing to guide transfusions in patients with massive bleeding due to trauma. C As per EAST 2020 guidelines, consider using thromboelastography/rotational thromboelastometry-guided strategy in adult trauma or surgical patients or critically ill patients with ongoing hemorrhage and concern for coagulopathy, to reduce blood product transfusions. C As per BSH 2018 guidelines, recognize that normal viscoelastic hemostatic assay results confer a high negative predictive value for transfusion need in trauma patients, enabling the clinical team to monitor the patient closely without immediate activation of the major hemorrhage protocol. B Show 2 more Diagnostic imaging: consider obtaining pre-hospital ultrasound to detect hemothorax/pneumothorax, hemopericardium, and/or free abdominal fluid in patients with thoracoabdominal injuries, if feasible, without delaying transport. C Show 2 more 2. Respiratory support Ventilation: perform endotracheal intubation or alternative airway management without delay in the presence of airway obstruction, altered consciousness (Glasgow Coma Scale 8), hypoventilation, or hypoxemia. B Show 2 more https://web.pathway.md/diseases/recfvXYVmcdhWmw2B 2/11 6/24/23, 4:09 PM Traumatic hemorrhage Pathway 3. Medical management General principles: minimize the time elapsed between injury and bleeding control. B Show 2 more Setting of care: transport severely injured patients directly to an appropriate trauma facility. B Prehospital bleeding control: As per ABC-T 2023 guidelines: Apply local compression of open wounds to limit life-threatening bleeding. B Place an adjunct tourniquet to stop life-threatening bleeding from open extremity injuries in the pre-surgical setting. B Prehospital transfusion: insufficient evidence to support the role of prehospital transfusion resuscitation with RBCs and plasma. Ensure it does not unduly add to transport delays if considered. I Local hemostatic measures: as per ABC-T 2023 guidelines, apply topical hemostatic agents in combination with other surgical measures or with packing for venous or moderate arterial bleeding associated with parenchymal injuries. B Mean arterial pressure targets: Use a restricted volume replacement strategy with a target systolic BP of 80-90 mmHg (mean arterial pressure 50-60 mmHg) in the initial phase following trauma until major bleeding has been stopped without clinical evidence of brain injury. B Maintain a mean arterial pressure 80 mmHg in patients with severe TBI (Glasgow Coma Scale 8). B Fluid resuscitation: As per ABC-T 2023 guidelines, initiate fluid therapy using 0.9% sodium chloride or balanced crystalloid solution in patients with hypotensive bleeding trauma. B Show 2 more As per SFAR 2022 guidelines, consider administering balanced crystalloids rather than 0.9% saline as first-line fluid therapy to reduce mortality and/or adverse renal events in patients with hemorrhagic shock. C Show 2 more Vasopressors and inotropes: Administer norepinephrine in addition to fluids to maintain target arterial pressure if a restricted volume replacement strategy does not achieve the target BP. B Administer infusion of dobutamine in the presence of myocardial dysfunction. B Recombinant factor VIIa: As per ABC-T 2023 guidelines: Do not use recombinant activated coagulation factor VII as the first-line treatment. D Consider administering recombinant activated coagulation factor VII (off-label) only if major bleeding and traumatic coagulopathy persist despite all other attempts to control bleeding, https://web.pathway.md/diseases/recfvXYVmcdhWmw2B 3/11 6/24/23, 4:09 PM Traumatic hemorrhage Pathway systemic homeostasis, and best-practice use of conventional hemostatic measures. C As per BSH 2022 guidelines, do not use recombinant activated factor VII in the management of major hemorrhage unless as part of a clinical trial. D As per EAST 2017 guidelines, insufficient evidence to make a recommendation for or against the use of recombinant factor VIIa in the management of severely injured adult trauma patients. Tranexamic acid: As per ABC-T 2023 guidelines: Administer tranexamic acid in patients with trauma with bleeding or at risk of significant bleeding as soon as possible, if feasible, en route to the hospital and within 3 hours after injury at a loading dose of 1 g infused over 10 minutes, followed by an IV infusion of 1 g over 8 hours. A Do not wait for results from a viscoelastic assessment to administer tranexamic acid. D As per BSH 2022 guidelines, administer tranexamic acid as soon as possible after injury (and no later than 3 hours) in patients with traumatic injury (including mild-moderate TBI). Administer 1 g bolus dose IV over 10 minutes followed by a maintenance infusion of 1 g over 8 hours. A As per ESICM 2021 guidelines: Administer early (< 3 hours from trauma) tranexamic acid in critically ill patients with bleeding or suspected bleeding due to trauma. A Consider administering tranexamic acid in critically ill patients with acute TBI and bleeding due to trauma. C As per BSH 2018 guidelines, do not withhold tranexamic acid based on the thromboelastography or rotational thromboelastometry parameters. D As per EAST 2017 guidelines, consider administering tranexamic acid as a hemostatic adjunct in severely injured adult trauma patients in a hospital setting. C Landmark trials: CRASH-2 In adult trauma patients with, or at risk of, significant bleeding, tranexamic acid was superior to placebo with respect to a all-cause death. CRASH- trial collaborators et al. Lancet. 2010 Jul 3. Other agents: do not use desmopressin or aprotinin in the management of major hemorrhage unless as part of a clinical trial. D Temperature control: consider applying early measures to reduce heat loss and warm the hypothermic patient to achieve and maintain normothermia. B Management of hypocalcemia: https://web.pathway.md/diseases/recfvXYVmcdhWmw2B 4/11 6/24/23, 4:09 PM Traumatic hemorrhage Pathway Monitor and maintain ionized calcium levels within the normal range following major trauma and especially during massive transfusion. B Administer calcium chloride to correct hypocalcemia. B Management of antithrombotics (VKAs): reverse (emergency) vitamin K-dependent OACs with the early use of both PCC and 5-10 mg IV phytomenadione (vitamin K1) in patients with bleeding trauma. A Management of antithrombotics (factor Xa inhibitors): consider measuring plasma levels of oral direct anti-factor Xa agents, such as apixaban, edoxaban, or rivaroxaban, in patients treated or suspected of being treated with one of these agents. C Show 3 more Management of antithrombotics (antiplatelets): reverse the effect of antiplatelet agents in patients with ongoing bleeding. B Show 4 more Management of antithrombotics (thrombin inhibitors): consider measuring dabigatran plasma levels using diluted TT in patients treated or suspected of being treated with dabigatran. C Show 2 more Thromboprophylaxis: initiate early mechanical thromboprophylaxis with intermittent pneumatic compression while the patient is immobile and has a bleeding risk. B Show 2 more 4. Inpatient care Coagulation monitoring: As per ABC-T 2023 guidelines: Obtain early and repeated monitoring of hemostasis using a traditional laboratory determination such as proTT/INR, Clauss fibrinogen level and platelet count, and/or point-of- care proTT/INR and/or a viscoelastic method. B Avoid using routine point-of-care platelet function devices for platelet function monitoring in patients with trauma on antiplatelet therapy or with suspected platelet dysfunction. D As per BSH 2022 guidelines, consider obtaining serial coagulation tests regularly, every 30-60 minutes depending on the severity of the hemorrhage, to guide and ensure the appropriate use of hemostatic blood components. B 5. Therapeutic procedures Transfusion strategies: As per ABC-T 2023 guidelines: Insufficient evidence to recommend in favor or against using pre-hospital blood products. Target Hgb levels of 70-90 g/L if RBC transfusion is necessary. B https://web.pathway.md/diseases/recfvXYVmcdhWmw2B 5/11 6/24/23, 4:09 PM Traumatic hemorrhage Pathway As per BSH 2022 guidelines: Set a standard threshold and target Hgb range for RBC transfusion to provide critical life- saving support in major bleeding alongside clinical judgment on the severity of bleeding (threshold Hgb 70 g/L, target range for the post-transfusion Hgb level of 70-90 g/L). B Administer universal components or appropriate substitutes to avoid delays in issuing blood during major bleeding if the patient's blood group is unknown or unsure. B As per ESICM 2021 guidelines: Consider using high-ratio transfusion strategies (at least 1 unit plasma per 2 units of PRBCs) over low-ratio transfusion strategies in critically ill patients with massive bleeding due to trauma. C Insufficient evidence to support the use of fixed high-ratio transfusion strategies in critically ill patients with non-traumatic massive bleeding. I As per EAST 2017 guidelines, target a high ratio of both plasma and platelets to RBCs for resuscitating severely injured bleeding trauma patients (e.g., 6 units plasma, 1 unit apheresis platelets, and 6 units RBC). B Plasma transfusion: As per ABC-T 2023 guidelines: Guide further use of FFP, if a fresh-frozen plasma-based coagulation resuscitation strategy is used, by standard laboratory coagulation screening parameters (proTT and/or aPTT > 1.5 times normal and/or viscoelastic evidence of a coagulation factor deficiency). B Avoid administering FFP to correct hypofibrinogenemia if fibrinogen concentrate and/or cryoprecipitate are available. D As per BSH 2022 guidelines, administer plasma (in a 1:1 ratio with RBCs) early as part of initial resuscitation in patients with major traumatic hemorrhage until results from coagulation monitoring are available. B Show 2 more As per ESICM 2021 guidelines, insufficient evidence to support the use of cryopreserved or cold-stored platelets in patients with massive or non-massive hemorrhage. I Coagulation factor transfusion: As per ABC-T 2023 guidelines, initiate monitoring and measures to support coagulation immediately upon hospital admission. B Show 7 more As per BSH 2022 guidelines, administer fibrinogen in patients with traumatic injury if fibrinogen levels fall < 1.5 g/L. B As per ESICM 2021 guidelines: Insufficient evidence to support the use of PCC versus plasma alone in patients with massive bleeding. I Insufficient evidence to support the use of early empiric fibrinogen replacement in critically ill patients with massive bleeding due to trauma. I https://web.pathway.md/diseases/recfvXYVmcdhWmw2B 6/11 6/24/23, 4:09 PM Traumatic hemorrhage Pathway Platelet transfusion: As per ABC-T 2023 guidelines, consider administering platelets to maintain a platelet count > 50 10 /L in patients with trauma with ongoing bleeding and > 100 10 /L in patients with TBI. C Show 2 more As per BSH 2022 guidelines, consider administering platelet transfusions to maintain platelet counts at > 50 10 /L if major bleeding is ongoing. C Cell salvage: As per ABC-T 2023 guidelines, consider performing cell salvage in patients with severe bleeding from an abdominal, pelvic, or thoracic cavity. C As per BSH 2022 guidelines: Insufficient evidence to support the universal policy of 24-hour cell salvage in patients with major bleeding. Evaluate the costs and benefits of running the cell salvage service in hospitals. I Consider performing cell salvage in patients refusing blood transfusion. B Resuscitative endovascular balloon occlusion of the aorta: consider performing REBOA in patients with non-compressible life-threatening traumatic hemorrhage to bridge the gap between hemodynamic collapse and hemorrhage control. C 6. Surgical interventions Damage-control surgery: perform damage control surgery in patients with severe injury presenting with hemorrhagic shock, signs of ongoing bleeding, coagulopathy, and/or combined abdominal vascular and pancreatic injuries. B Show 2 more 7. Specific circumstances Pediatric patients (prehospital management): Consider administering prehospital transfusion by out-of-hospital emergency medical service based on product availability and clinical judgment in traumatically injured pediatric patients with hemorrhagic shock. E Avoid using a permissive hypotension strategy in traumatically injured pediatric patients with hemorrhagic shock. Consider setting resuscitation goals optimizing end-organ perfusion and adequate oxygen delivery. D Pediatric patients (local hemostatic measures): place commercially available tourniquets (by individuals with training) in traumatically injured pediatric patients with exsanguinating extremity hemorrhage. E Pediatric patients (transfusion strategies): consider using an initial empiric resuscitation approach using massive transfusion protocols and balanced blood product administration in traumatically injured pediatric patients with hemorrhagic shock. E https://web.pathway.md/diseases/recfvXYVmcdhWmw2B 7/11 6/24/23, 4:09 PM Traumatic hemorrhage Pathway Show 4 more Pediatric patients (hemostatic agents): prefer tranexamic acid over aminocaproic acid when an antifibrinolytic agent is needed in traumatically Injured pediatric patients with hemorrhagic shock. E Consider administering empiric tranexamic acid within 3 hours of injury in traumatically injured pediatric patients with hemorrhagic shock. B Show 2 more Pediatric patients (monitoring): Consider obtaining adjunctive viscoelastic monitoring in traumatically injured pediatric patients with hemorrhagic shock. E Consider using a goal-directed resuscitation strategy following initial empirical resuscitation to optimize hemostasis and correct coagulopathy in traumatically injured pediatric patients with hemorrhagic shock. E Patients with pelvic trauma, diagnostic imaging: As per WSES 2017 guidelines: Obtain eFAST and pelvic XR in hemodynamically and mechanically unstable patients with pelvic trauma, in order to identify injuries requiring pelvic stabilization, angiography, a rapid reductive maneuver, and/or laparotomy. B Obtain CT of the abdomen and pelvis with IV contrast to exclude pelvic hemorrhage in hemodynamically stable patients with pelvic trauma. Use 3D bone reconstruction to reduce the tissue damage during invasive procedures, the risk of neurological disorders after surgical fixation, operative time, and irradiation and the required expertise. B As per EAST 2011 guidelines, avoid relying on FAST results to exclude intraperitoneal bleeding in the presence of a pelvic fracture. D Show 4 more Patients with pelvic trauma, pelvic binders and orthotic devices: As per ABC-T 2023 guidelines, place a pelvic binder as an adjunct in the pre-hospital setting to limit life-threatening bleeding in the presence of a suspected pelvic fracture. B As per WSES 2017 guidelines, apply noninvasive external pelvic compression as an early strategy to stabilize the pelvic ring and decrease the amount of pelvic hemorrhage in the early resuscitation phase. A Prefer pelvic binders over sheet wrapping. B Show 2 more As per EAST 2011 guidelines, apply temporary pelvic binders to reduce unstable pelvic fractures as well as definitive stabilization and decrease pelvic volume. B Show 3 more Patients with pelvic trauma, pelvic ring stabilization: As per ABC-T 2023 guidelines, perform pelvic ring closure and stabilization as early as possible in patients with pelvic ring disruption in hemorrhagic shock. B As per WSES 2017 guidelines, perform external pelvic fixation to provide rigid temporary pelvic ring stability and aid in early hemorrhage control in hemodynamically unstable patients with pelvic ring disruptions. A https://web.pathway.md/diseases/recfvXYVmcdhWmw2B 8/11 6/24/23, 4:09 PM Traumatic hemorrhage Pathway Show 3 more Patients with pelvic trauma, angioembolization: As per SIR 2020 guidelines, perform embolization as first-line therapy and the standard of care over surgery in patients with pelvic trauma. B As per ABC-T 2019 guidelines, perform angiographic embolization in patients with ongoing hemodynamic instability despite adequate pelvic ring stabilization. B As per WSES 2017 guidelines, consider performing angiography/embolization in patients with pelvic fracture and hemodynamic instability or evidence of ongoing bleeding, after pelvic stabilization, initiation of aggressive hemostatic resuscitation, and exclusion of extra-pelvic sources of blood loss. B Show 3 more As per EAST 2011 guidelines, do not rely on the presence/location of hematoma to predict or exclude the need for angiography and possible embolization. Recognize that pelvic hematoma > 500 cm in size has an increased incidence of arterial injury and need for angiography. D Show 7 more Patients with pelvic trauma, retroperitoneal packing: As per ABC-T 2023 guidelines, perform temporary extraperitoneal packing when bleeding is ongoing and/or when angioembolization cannot be achieved promptly. Consider combining extraperitoneal packing with open abdominal surgery when necessary. B As per EAST 2011 guidelines: Perform retroperitoneal pelvic packing as a salvage technique to control hemorrhage after angioembolization. B Perform retroperitoneal pelvic packing to control hemorrhage as part of a multidisciplinary clinical pathway including a pelvic orthotic device/C-clamp. B Patients with pelvic trauma, REBOA: As per ABC-T 2019 guidelines, consider performing aortic balloon occlusion only under extreme circumstances in patients with a pelvic fracture to gain time until appropriate bleeding control measures can be implemented. C As per WSES 2017 guidelines, consider performing REBOA in zone III in hemodynamically unstable patients (systolic BP < 90 mmHg or lack of hemodynamic response to blood product transfusion) with suspected pelvic hemorrhage. C Show 3 more Patients with pelvic trauma, surgical bleeding control: As per ABC-T 2019 guidelines, perform early surgical bleeding control in patients with ongoing hemodynamic instability despite adequate pelvic ring stabilization. B As per WSES 2017 guidelines, perform resuscitative thoracotomy with aortic cross-clamping to achieve temporary control of hemorrhage in patients with exsanguinating traumatic hemorrhage. A https://web.pathway.md/diseases/recfvXYVmcdhWmw2B 9/11 6/24/23, 4:09 PM Traumatic hemorrhage Pathway 8. Quality improvement Care protocols: As per ABC-T 2023 guidelines: Ensure local implementation of evidence-based guidelines for the management of patients with bleeding trauma. B Ensure that local clinical quality and safety management systems include parameters to assess key measures of bleeding control and outcome. B As per BSH 2022 guidelines, ensure that hospitals have local major hemorrhage protocols in relevant clinical areas, including a clear mechanism for contacting all relevant team members and support personnel. B Show 8 more As per EAST 2017 guidelines, develop and implement a massive transfusion / damage control resuscitation protocol for the management of severely injured trauma patients. Apply the most current evidence to guide indications for protocol activation, target blood product ratios, other aspects of protocol implementation. B References 1. Robert T Russell, Joseph R Esparaz, Michael A Beckwith et al. Pediatric traumatic hemorrhagic shock consensus conference recommendations. J Trauma Acute Care Surg. 2023 Jan 1;94 1S Suppl 1 S2 S10. Open 2. Rolf Rossaint, Arash Afshari, Bertil Bouillon et al. The European guideline on management of major bleeding and coagulopathy following trauma: sixth edition. Crit Care. 2023 Mar 1;27 1 80. Open 3. Simon J Stanworth, Kerry Dowling, Nikki Curry et al. A guideline for the haematological management of major haemorrhage: a British Society for Haematology Guideline. Br J Haematol. 2022 Jun 10. Open 4. Donat R Spahn, Bertil Bouillon, Vladimir Cerny et al. The European guideline on management of major bleeding and coagulopathy following trauma: fifth edition. Crit Care. 2019 Mar 27;23 1 98. Open 5. Alexander P J Vlaar, Joanna C Dionne, Sanne de Bruin et al. Transfusion strategies in bleeding critically ill adults: a clinical practice guideline from the European Society of Intensive Care Medicine. Intensive Care Med. 2021 Dec;47 12 1368 1392. Open 6. Coccolini F, Stahel PF, Montori G et al. Pelvic trauma: WSES classification and guidelines. World J Emerg Surg. 2017 Jan 18;12 5. Open 7. Bulger EM, Snyder D, Schoelles K et al. An evidence-based prehospital guideline for external hemorrhage control: American College of Surgeons Committee on Trauma. Prehosp Emerg Care. 2014 Apr- Jun;18 2 163 73. Open 8. Cullinane DC, Schiller HJ, Zielinski MD et al. Eastern Association for the Surgery of Trauma practice management guidelines for hemorrhage in pelvic fracture update and systematic review. J Trauma. 2011 Dec;71 6 1850 68. Open https://web.pathway.md/diseases/recfvXYVmcdhWmw2B 10/11 6/24/23, 4:09 PM Traumatic hemorrhage Pathway 9. Olivier Joannes-Boyau, Philippe Le Conte, Marie-Pierre Bonnet et al. Guidelines for the choice of intravenous fluids for vascular filling in critically ill patients, 2021. Anaesth Crit Care Pain Med. 2022 Jun;41 3 101058. Open 10. Cannon JW, Khan MA, Raja AS et al. Damage control resuscitation in patients with severe traumatic hemorrhage: A practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg. 2017 Mar;82 3 605 617. Open 11. Nikolay Bugaev, John J Como, Guy Golani et al. Thromboelastography and rotational thromboelastometry in bleeding patients with coagulopathy: Practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg. 2020 Dec;89 6 999 1017. Open 12. Nicola S Curry, Ross Davenport, Sue Pavord et al. The use of viscoelastic haemostatic assays in the management of major bleeding: A British Society for Haematology Guideline. Br J Haematol. 2018 Sep;182 6 789 806. Open 13. Siddharth A Padia, Christopher R Ingraham, John M Moriarty et al. Society of Interventional Radiology Position Statement on Endovascular Intervention for Trauma. J Vasc Interv Radiol. 2020 Mar;31 3 363 369.e2. Open 14. K Baksaas-Aasen, L S Gall, J Stensballe et al. Viscoelastic haemostatic assay augmented protocols for major trauma haemorrhage ITACTIC a randomized, controlled trial. Intensive Care Med. 2021 Jan;47 1 49 59. Open 15. Nedim Y cel, Rolf Lefering, Marc Maegele et al. Trauma Associated Severe Hemorrhage TASH Score: probability of mass transfusion as surrogate for life threatening hemorrhage after multiple trauma. J Trauma. 2006 Jun;60 6 1228 36; discussion 1236 7. Open 16. Pierre Bouzat, Jonathan Charbit, Paer-Selim Abback et al. Efficacy and Safety of Early Administration of 4 Factor Prothrombin Complex Concentrate in Patients With Trauma at Risk of Massive Transfusion: The PROCOAG Randomized Clinical Trial. JAMA. 2023 Apr 25;329 16 1367 1375. Open 17. PATCH Trauma Investigators and the ANZICS Clinical Trials Group, Russell L Gruen, Biswadev Mitra et al. Prehospital Tranexamic Acid for Severe Trauma. N Engl J Med. 2023 Jun 14. Open https://web.pathway.md/diseases/recfvXYVmcdhWmw2B 11/11