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Traumatic hemorrhage

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Updated 2023 ABC-T guidelines for the diagnosis and management of traumatic hemorrhage.

Guidelines

Key sources

The following summarized guidelines for the evaluation and management of traumatic hemorrhage are prepared by our editorial team based on guidelines from the Agency for Healthcare Research and Quality (AHRQ 2024), the Pan-European Multidisciplinary Task Force for Advanced Bleeding Care in Trauma (ABC-T 2023,2019), the Pediatric Traumatic Hemorrhagic Shock Consensus Conference (PTHSCC 2023), the British Society for Haematology (BSH 2022,2018), ...
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Diagnostic investigations

Initial assessment: as per ABC-T 2023 guidelines, assess the extent of traumatic hemorrhage clinically using a combination of patient physiology, anatomical injury pattern, mechanism of injury, and the patient response to initial resuscitation.
B
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  • Laboratory testing

  • Coagulation and viscoelastic testing

  • Diagnostic imaging

Respiratory support

Airway management: as per AHRQ 2024 guidelines, consider using either a bag-valve mask alone or a supraglottic airway for airway management in adult patients with trauma.
C
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Medical management

General principles: as per ABC-T 2023 guidelines, minimize the time elapsed between injury and bleeding control.
B
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  • Setting of care

  • Prehospital bleeding control

  • Prehospital transfusion

  • Local hemostatic measures

  • Mean arterial pressure targets

  • Fluid resuscitation

  • Vasopressors and inotropes

  • Recombinant factor VIIa

  • Tranexamic acid

  • Other agents

  • Temperature control

  • Management of hypocalcemia

  • Management of antithrombotics (VKAs)

  • Management of antithrombotics (factor Xa inhibitors)

  • Management of antithrombotics (antiplatelets)

  • Management of antithrombotics (thrombin inhibitors)

  • Thromboprophylaxis

Inpatient care

Coagulation monitoring
As per ABC-T 2023 guidelines:
Obtain early and repeated monitoring of hemostasis using a traditional laboratory determination such as PT/INR, Clauss fibrinogen level and platelet count, and/or point-of-care PT/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

Therapeutic procedures

Transfusion strategies
As per ABC-T 2023 guidelines:
Insufficient evidence to recommend in favor or against using pre-hospital blood products.
Target hemoglobin levels of 70-90 g/L if RBC transfusion is necessary.
B

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  • Plasma transfusion

  • Coagulation factor transfusion

  • Platelet transfusion

  • Cell salvage

  • REBOA

Surgical interventions

Damage-control surgery: as per ABC-T 2023 guidelines, 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
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Specific circumstances

Pediatric patients, prehospital management
As per PTHSCC 2023 guidelines:
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

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  • Pediatric patients (local hemostatic measures)

  • Pediatric patients (transfusion strategies)

  • Pediatric patients (hemostatic agents)

  • Pediatric patients (monitoring)

  • Patients with pelvic trauma (diagnostic imaging)

  • Patients with pelvic trauma (pelvic binders and orthotic devices)

  • Patients with pelvic trauma (pelvic ring stabilization)

  • Patients with pelvic trauma (angioembolization)

  • Patients with pelvic trauma (retroperitoneal packing)

  • Patients with pelvic trauma (REBOA)

  • Patients with pelvic trauma (surgical bleeding control)

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