Management of Critical Bleeding in Trauma Patients: Between Recommendations and Reality

Abstract

Uncontrollable haemorrhage is the most frequent cause of early death in trauma patients. Massive haemorrhage may be exacerbated by coagulopathy early after trauma, and may transit to critical bleeding that does not respond to surgical haemostasis. The treatment strategies should focus on achieving haemostasis as soon as possible and correcting coagulopathy; otherwise efforts at resuscitation are likely to be useless. Rapid control of the source of bleeding with damage control techniques instead of complete repair, interventional radiology especially in abdominal-pelvic trauma, use of blood derived products and haemostatic agents are essential. Rotational thrombelastometry is used to promptly assess coagulation, but when it is not available, routine laboratory-based coagulation tests may be used for assessment of fibrinolysis. Early coagulation support may prevent acquired coagulopathy. The recommendations to avoid critical bleeding are constantly updated but in many situations, due to limited resources they cannot be applied completely. Recognizing the predictors of mortality with early monitoring of prothrombin time, activated partial thromboplastin time, fibrinogen and platelets, target haemostatic therapy with lysine derivates and substituted coagulation factors in order to avoid packed red blood cells and fresh frozen plasma, are of vital importance. Protocol for the treatment of patient with major bleeding will depend on rational strategy which relies on the resources available. Tranexemic acid should be given in massive bleeding, even in the absence of clinically diagnosed hyperfibrinolysis. Fibrinogen and platelets have to be administered in order to provide thrombin formation when hyperfibrinolysis is considered. Bleeding that continues despite fibrin supplementation and adequate number of platelets may be a result of insufficient thrombin formation; in this case prothrombin complex concentrates may be the first line therapy for thrombin deficiency. Strategy in treatment of trauma patients relies on resource availability