Massive haemorrhage: a current perspective

Abstract

Trauma and massive haemorrhage are associated with coagulopathy secondary to tissue injury, hypoperfusion, dilution, and consumption of clotting factors and platelets occurring already at the scene of the accident. Concepts of damage control surgery have evolved prioritizing early control of the cause of bleeding by non-definitive means, while haemostatic control resuscitation seeks early control of coagulopathy. Haemostatic resuscitation provides transfusions with plasma and platelets in addition to red blood cells in an immediate and sustained manner as part of the transfusion protocol for massively bleeding patients and consequently limiting the amount of crystalloids and colloids are crucial for avoiding further impairment of haemostatic competence. Transfusion of red blood cells, plasma and platelets in a similar proportion as in whole blood prevents both hypovolaemia and coagulopathy. Results from recent before-and-after studies in massively bleeding patients indicate that trauma exsanguination protocols involving early administration of plasma and platelets are associated with improved survival. Furthermore, viscoelastic whole blood assays, such as thrombelastography (TEG) appear advantageous for identifying coagulopathy in trauma patients with severe haemorrhage as opposed the conventional coagulation assays. In our view, patients with uncontrolled bleeding, including trauma patients, should be treated with goal-directed haemostatic control resuscitation involving early administration of plasma and platelets and based on the results of TEG analysis. The aim of the goal-directed therapy should be to maintain a normal haemostatic competence until surgical haemostasis is achieved, as this appears to be associated with reduced mortality.