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

（这篇文章下了很久了，一直放着，用Chatgpt 4整理了一下放上来，大致看了下应该和原文¹一样。）

I. Initial resuscitation and prevention of further bleeding

• Recommendation 1: We recommend that severely injured patients be transported directly to an appropriate trauma facility (Grade 1B).
• Recommendation 2: We recommend local compression of open wounds to limit life-threatening bleeding (Grade 1B).
• Recommendation 3: We recommend that endotracheal intubation or alternative airway management be performed without delay in the presence of airway obstruction, altered consciousness (Glasgow Coma Scale ≤ 8), hypoventilation or hypoxaemia (Grade 1B).
• Recommendation 4: No clear recommendation or suggestion in favour or against the use of pre-hospital blood products can be provided at this time.

II. Diagnosis and monitoring of bleeding

• Recommendation 5: We recommend that the physician clinically assess the extent of traumatic haemorrhage using a combination of patient physiology, anatomical injury pattern, mechanism of injury, and the patient response to initial resuscitation (Grade 1C).
• Recommendation 6: We recommend that patients with an obvious bleeding source and those presenting with haemorrhagic shock in extremis and a suspected source of bleeding undergo an immediate bleeding control procedure (Grade 1B).
• Recommendation 7: We recommend that patients with an unidentified source of bleeding but without a need for immediate bleeding control undergo immediate further investigation to determine the bleeding source (Grade 1C).
• Recommendation 8: We suggest the use of pre-hospital ultrasonography (PHUS) for the detection of haemo-/pneumothorax, haemopericardium, and/or free abdominal fluid in patients with thoracoabdominal injuries if feasible without delaying transport (Grade 2B).
• Recommendation 9: We recommend the use of repeated Hb and/or Hct measurements as a laboratory marker for bleeding as an initial value in the normal range may mask early-phase bleeding (Grade 1B).
• Recommendation 10: We recommend blood lactate as a sensitive test to estimate and monitor the extent of bleeding and tissue hypoperfusion; in the absence of lactate measurements, base deficit may represent a suitable alternative (Grade 1B).
• Recommendation 11: We recommend the early and repeated monitoring of haemostasis using either a traditional laboratory determination such as prothrombin time (PT)/international normalised ratio (INR), Clauss fibrinogen level, and platelet count, and/or point-of-care (POC) PT/INR and/or a viscoelastic method (Grade 1C).

III. Tissue oxygenation volume fluids and temperature

• Recommendation 13: In the initial phase following trauma, we recommend the use of a restricted volume replacement strategy with a target systolic blood pressure of 80–90 mmHg (mean arterial pressure 50–60 mmHg) until major bleeding has been stopped without clinical evidence of brain injury (Grade 1B).
• Recommendation 14: If a restricted volume replacement strategy does not achieve the target blood pressure, we recommend the administration of noradrenaline in addition to fluids to maintain target arterial pressure (Grade 1C).
• Recommendation 15: We recommend that fluid therapy using a 0.9% sodium chloride or balanced crystalloid solution be initiated in the hypotensive bleeding trauma patient (Grade 1B).
• Recommendation 16: If erythrocyte transfusion is necessary, we recommend a target haemoglobin of 70–90 g/L (Grade 1C).
• Recommendation 17: We suggest that cell salvage be considered in the presence of severe bleeding from an abdominal, pelvic, or thoracic cavity (Grade 2B).
• Recommendation 18: We recommend early application of measures to reduce heat loss and warm the hypothermic patient to achieve and maintain normothermia (Grade 1C).

IV. Rapid control of bleeding

• Recommendation 19: We recommend damage control surgery in the severely injured patient presenting with haemorrhagic shock, signs of ongoing bleeding, coagulopathy, and/or combined abdominal, vascular, and pancreatic injuries (Grade 1B).
• Recommendation 20: We recommend the adjunct use of a pelvic binder in the pre-hospital setting to limit life-threatening bleeding in the presence of a suspected pelvic fracture (Grade 1C).
• Recommendation 21: We recommend temporary extraperitoneal packing when bleeding is ongoing and/or when angioembolisation cannot be achieved in a timely manner. Extraperitoneal packing can be combined with open abdominal surgery when necessary (Grade 1C).

V. Initial management of bleeding and coagulopathy

• Recommendation 22: We 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 (Grade 1B).
• Recommendation 23: We recommend that tranexamic acid (TXA) be administered to the trauma patient who is 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 min, followed by an i.v. infusion of 1 g over 8 hours (Grade 1A).
• Recommendation 24: We recommend that monitoring and measures to support coagulation be initiated immediately upon hospital admission (Grade 1B).
• Recommendation 25: In the initial management of patients with expected massive haemorrhage, we recommend one of the two following strategies: Fibrinogen concentrate or cryoprecipitate and pRBC (Grade 1C) or FFP or pathogen-inactivated FFP in a FFP/pRBC ratio of at least 1:2 as needed (Grade 1C). In addition, we suggest a high platelet/pRBC ratio (Grade 2B).
• Recommendation 26: We recommend that resuscitation measures be continued using a goal-directed strategy guided by standard laboratory coagulation values and/or VEM (Grade 1B).
• Recommendation 27: If a FFP-based coagulation resuscitation strategy is used, we recommend that further use of FFP be guided by standard laboratory coagulation screening parameters (PT and/or APTT >1.5 times normal and/or viscoelastic evidence of a coagulation factor deficiency) (Grade 1C). We recommend that the use of FFP be avoided for the correction of hypofibrinogenemia if fibrinogen concentrate and/or cryoprecipitate are available (Grade 1C).
• Recommendation 28: If a CFC-based strategy is used, we recommend treatment with factor concentrates based on standard laboratory coagulation parameters and/or viscoelastic evidence of a functional coagulation factor deficiency (Grade 1C). Provided that fibrinogen levels are normal, we suggest that prothrombin complex concentrate (PCC) is administered to the bleeding patient based on evidence of delayed coagulation initiation using VEM (Grade 2C). We suggest that monitoring of FXIII be included in coagulation support algorithms and that FXIII be supplemented in bleeding patients with a functional FXIII deficiency (Grade 2C).
• Recommendation 29: We recommend treatment with fibrinogen concentrate or cryoprecipitate if major bleeding is accompanied by hypofibrinogenemia (viscoelastic signs of a functional fibrinogen deficit or a plasma Clauss fibrinogen level ≤ 1.5 g/L) (Grade 1C). We suggest 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 should be guided by VEM and laboratory assessment of fibrinogen levels (Grade 2C).

VII. Management of antithrombotic agents

• Recommendation 30: We suggest that platelets be administered to maintain a platelet count above 50 × 109/L in trauma patients with ongoing bleeding and above 100 × 109/L in patients with TBI (Grade 2C). If administered, we suggest an initial dose of four to eight single platelet units or one aphaeresis pack (Grade 2B).
• Recommendation 31: We recommend that ionised calcium levels be monitored and maintained within the normal range following major trauma and especially during massive transfusion (Grade 1C). We recommend the administration of calcium chloride to correct hypocalcaemia (Grade 1C).
• Recommendation 32: We do not recommend the use of recombinant activated coagulation factor VII (rFVIIa) as first-line treatment (Grade 1B). We suggest that the off-label use of rFVIIa be considered only if major bleeding and traumatic coagulopathy persist despite all other attempts to control bleeding, systemic homeostasis, and best-practice use of conventional haemostatic measures (Grade 2C).
• Recommendation 33: In the bleeding trauma patient, we recommend the emergency reversal of vitamin K-dependent oral anticoagulants with the early use of both PCC and 5–10 mg i.v. phytomenadione (vitamin K1) (Grade 1A).
• Recommendation 34: We suggest the measurement of plasma levels of oral direct antifactor Xa agents such as apixaban, edoxaban, or rivaroxaban in patients treated or suspected of being treated with one of these agents (Grade 2C). We suggest that measurement of anti-Xa activity be calibrated for the specific agent. If not possible or available, we suggest low molecular weight heparin (LMWH)-calibrated anti-Xa assays as a reliable alternative (Grade 2C). If bleeding is life-threatening in the presence of an apixaban or rivaroxaban effect, especially in patients with TBI, we suggest reversal with andexanet alfa (Grade 2C). If andexanet alfa is not available or in patients receiving edoxaban, we suggest the administration of PCC (25–50 U/kg) (Grade 2C).
• Recommendation 35: We suggest the measurement of dabigatran plasma levels using diluted thrombin time in patients treated or suspected of being treated with dabigatran (Grade 2C). If measurement is not possible or available, we suggest measurement of the standard thrombin time to allow a qualitative estimation of the presence of dabigatran (Grade 2C). If bleeding is life-threatening in those receiving dabigatran, we recommend treatment with idarucizumab (i.v. 5 g) (Grade 1C).

VIII. Thromboprophylaxis

• Recommendation 37: We recommend early initiation of mechanical thromboprophylaxis with intermittent pneumatic compression (IPC) while the patient is immobile and has a bleeding risk (Grade 1C). We recommend combined pharmacological and IPC thromboprophylaxis within 24 hours after bleeding has been controlled and until the patient is mobile (Grade 1B). We do not recommend the use of graduated compression stockings for thromboprophylaxis (Grade 1C). We do not recommend the routine use of inferior vena cava filters as thromboprophylaxis (Grade 1C).

IX. Guideline implementation and quality control

• Recommendation 38: We recommend the local implementation of evidence-based guidelines for management of the bleeding trauma patient (Grade 1B).
• Recommendation 39: We recommend that local clinical quality and safety management systems include parameters to assess key measures of bleeding control and outcome (Grade 1B).

1. Rossaint R, Afshari A, Bouillon B, Cerny V, Cimpoesu D, Curry N, Duranteau J, Filipescu D, Grottke O, Grønlykke L, Harrois A, Hunt BJ, Kaserer A, Komadina R, Madsen MH, Maegele M, Mora L, Riddez L, Romero CS, Samama CM, Vincent JL, Wiberg S, Spahn DR. The European guideline on management of major bleeding and coagulopathy following trauma: sixth edition. Crit Care. 2023 Mar 1;27(1):80. doi: 10.1186/s13054-023-04327-7. PMID: 36859355; PMCID: PMC9977110. ↩