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Management of bleeding and coagulopathy following major trauma: an updated European guideline

Donat R Spahn1, Bertil Bouillon2, Vladimir Cerny34, Timothy J Coats5, Jacques Duranteau6, Enrique Fernández-Mondéjar7, Daniela Filipescu8, Beverley J Hunt9, Radko Komadina10, Giuseppe Nardi11, Edmund Neugebauer12, Yves Ozier13, Louis Riddez14, Arthur Schultz15, Jean-Louis Vincent16 and Rolf Rossaint17*

Author Affiliations

1 Institute of Anaesthesiology, University Hospital Zurich, Rämistrasse 100, CH-8091 Zurich, Switzerland

2 Department of Trauma and Orthopaedic Surgery, University of Witten/Herdecke, Cologne-Merheim Medical Centre, Ostmerheimerstrasse 200, D-51109 Cologne, Germany

3 Faculty of Medicine in Hradec Králové, Department of Anaesthesiology and Intensive Care Medicine, University Hospital Hradec Králové, CZ-50005 Hradec Králové, Czech Republic

4 Dalhousie University, Department of Anesthesia, Pain Management and Perioperative Medicine, Halifax, NS B3H 4R2, Canada

5 Accident and Emergency Department, University of Leicester, Infirmary Square, Leicester LE1 5WW, UK

6 Department of Anaesthesia and Intensive Care, University of Paris XI, Faculté de Médecine Paris-Sud, 63 rue Gabriel Péri, F-94276 Le Kremlin-Bicêtre, France

7 Department of Emergency and Critical Care Medicine, University Hospital Virgen de las Nieves, ctra de Jaén s/n, E-18013 Granada, Spain

8 Department of Cardiac Anaesthesia and Intensive Care, C. C. Iliescu Emergency Institute of Cardiovascular Diseases, Sos Fundeni 256-258, RO-022328 Bucharest, Romania

9 Guy's and St Thomas' Foundation Trust, Westminster Bridge Road, London, SE1 7EH, UK

10 Department of Traumatology, General and Teaching Hospital Celje, SI-3000 Celje, Slovenia

11 Shock and Trauma Centre, S. Camillo Hospital, Viale Gianicolense 87, I-00152 Rome, Italy

12 Institute for Research in Operative Medicine (IFOM), Witten/Herdecke University, Campus Cologne, Ostmerheimerstrasse 200, D-51109 Cologne, Germany

13 Division of Anaesthesia, Intensive Care and Emergency Medicine, Brest University Hospital, Boulevard Tanguy Prigent, F-29200 Brest, France

14 Department of Surgery and Trauma, Karolinska University Hospital, S-171 76 Solna, Sweden

15 Ludwig-Boltzmann-Institute for Experimental and Clinical Traumatology, Lorenz Boehler Trauma Centre, Donaueschingenstrasse 13, A-1200 Vienna, Austria

16 Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik 808, B-1070 Brussels, Belgium

17 Department of Anaesthesiology, University Hospital Aachen, RWTH Aachen University, Pauwelsstrasse 30, D-52074 Aachen, Germany

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Critical Care 2013, 17:R76  doi:10.1186/cc12685

Published: 19 April 2013



Evidence-based recommendations are needed to guide the acute management of the bleeding trauma patient. When these recommendations are implemented patient outcomes may be improved.


The multidisciplinary Task Force for Advanced Bleeding Care in Trauma was formed in 2005 with the aim of developing a guideline for the management of bleeding following severe injury. This document represents an updated version of the guideline published by the group in 2007 and updated in 2010. Recommendations were formulated using a nominal group process, the Grading of Recommendations Assessment, Development and Evaluation (GRADE) hierarchy of evidence and based on a systematic review of published literature.


Key changes encompassed in this version of the guideline include new recommendations on the appropriate use of vasopressors and inotropic agents, and reflect an awareness of the growing number of patients in the population at large treated with antiplatelet agents and/or oral anticoagulants. The current guideline also includes recommendations and a discussion of thromboprophylactic strategies for all patients following traumatic injury. The most significant addition is a new section that discusses the need for every institution to develop, implement and adhere to an evidence-based clinical protocol to manage traumatically injured patients. The remaining recommendations have been re-evaluated and graded based on literature published since the last edition of the guideline. Consideration was also given to changes in clinical practice that have taken place during this time period as a result of both new evidence and changes in the general availability of relevant agents and technologies.


A comprehensive, multidisciplinary approach to trauma care and mechanisms with which to ensure that established protocols are consistently implemented will ensure a uniform and high standard of care across Europe and beyond.

Please see related letter by Morel et al webcite