title: Coagulation management in multiple trauma: a systematic review.
abstract: OBJECTIVE
  The management of trauma patients suffering from active bleeding has improved with a better understanding of trauma-induced coagulopathy. The aim of this manuscript is to give recommendations for coagulation management.
  
  
  METHODS
  A systematic literature search in the PubMed database was performed for articles published between January 2000 and August 2009. A total of 230 articles were included in the present systematic review.
  
  
  CONCLUSIONS
  The "coagulopathy of trauma" is a discrete disease which has a decisive influence on survival. Diagnosis and therapy of deranged coagulation should start immediately after admission to the emergency department. A specific protocol for massive transfusion should be introduced and continued. Loss of body temperature should be prevented and treated. Acidaemia should be prevented and treated by appropriate shock therapy. If massive transfusion is performed using fresh frozen plasma (FFP), a ratio of FFP to pRBC (packed red blood cells) of 1:2-1:1 should be achieved. Fibrinogen should be substituted at levels of <1.5 g/L. For patients suffering from active bleeding, permissive hypotension (i.e. mean arterial pressure ~65 mmHg) may be aimed for until surgical cessation of bleeding. This option is contraindicated in injuries of the central nervous system and in patients with coronary heart disease, or with known hypertension. Thrombelastography or -metry may be performed to guide coagulation diagnosis and substitution. Hypocalcaemia <0.9 mmol/L should be avoided and may be treated. For actively bleeding patients, pRBC may be given at haemoglobin <10 g/L (6.2 mmol/L) and haematocrit may be targeted at 30%.
authors.affiliation: Department of Anaesthesiology and Intensive Care Medicine, University Hospital Cologne, Cologne, Germany. heiko.lier@uk-koeln.de
authors.forename: Heiko
authors.initials: H
authors.lastname: Lier
authors.forename: Bernd W
authors.initials: BW
authors.lastname: Böttiger
authors.forename: Jochen
authors.initials: J
authors.lastname: Hinkelbein
authors.forename: Henning
authors.initials: H
authors.lastname: Krep
authors.forename: Michael
authors.initials: M
authors.lastname: Bernhard
mesh_terms: D001777:Blood Coagulation / Q000187:drug effects; D001778:Blood Coagulation Disorders / Q000188:drug therapy* / Q000601:surgery; D016913:Blood Component Transfusion; D006801:Humans; D009104:Multiple Trauma / Q000097:blood* / Q000628:therapy; D010949:Plasma; D013916:Thrombelastography