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Traumatic hemorrhage

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 Pan-European Multidisciplinary Task Force for Advanced Bleeding Care in Trauma (ABC-T 2023; 2019), the Agency for Healthcare Research and Quality (AHRQ 2023), the Pediatric Traumatic Hemorrhagic Shock Consensus Conference (PTHSCC 2023), 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).
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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 initial resuscitation.
B
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  • Laboratory testing

  • Coagulation and viscoelastic testing

  • Diagnostic imaging

2.Respiratory support

Airway management: as per ABC-T 2023 guidelines, perform endotracheal intubation or alternative airway management without delay in the presence of airway obstruction, altered consciousness (GCS ≤ 8), hypoventilation, or hypoxemia.
B
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3.Medical management

General principles: 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

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 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

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 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

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
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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

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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)

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