title: Diversity in clinical management and protocols for the treatment of major bleeding trauma patients across European level I Trauma Centres.
abstract: BACKGROUND
  Uncontrolled haemorrhage is still the leading cause of preventable death after trauma and the primary focus of any treatment strategy should be related to early detection and control of blood loss including haemostasis.
  
  
  METHODS
  For assessing management practices across six European level I trauma centres with academic interest and research in the field of coagulopathy an online survey was conducted addressing local management practice for bleeding trauma patients including algorithms for detection, management and monitoring coagulation disorders and immediate interventions. Each centre provided their locally applied massive transfusion protocol.
  
  
  RESULTS
  All participating trauma centres have developed and implemented a local algorithm and protocol for the bleeding trauma patient. These are uniformly activated by clinical triggers and deactivated once the bleeding has stopped according to clinical assessment in combination with laboratory signs of achieved haemostasis. The severity of coagulopathy and shock is mostly assessed via standard coagulation tests and partially used extended viscoelastic tests. All centres have implemented the immediate use of tranexamic acid. Initial resuscitation is started either pre-hospital or after hospital admission by using transfusion packages with pre-fixed universal blood product combinations and ratios following the concept of "damage control resuscitation" at which applied ratios substantially vary. Two centres initially start with transfusion packages but with viscoelastic tests running in parallel to quickly allow a shift towards a viscoelastic test-guided therapy.
  
  
  CONCLUSIONS
  Diversity in the management of bleeding trauma patients such as pre-hospital blood administration and routinely performed viscoelastic tests exists even among level I trauma centres. The paucity of consensus among these centres highlights the need for further primary research followed by clinical trials to improve the evidence for sophisticated guidelines and strategies.
authors.affiliation: Institute for Research in Operative Medicine (IFOM), Witten/Herdecke University (Campus Cologne-Merheim), Ostmerheimerstr. 200, 51109, Cologne, Germany.
authors.forename: Nadine
authors.initials: N
authors.lastname: Schäfer
authors.affiliation: Institute for Research in Operative Medicine (IFOM), Witten/Herdecke University (Campus Cologne-Merheim), Ostmerheimerstr. 200, 51109, Cologne, Germany.|Department of Orthopaedic Surgery, Traumatology and Sports Traumatology, Cologne-Merheim Medical Center (CMMC), Witten/Herdecke University (Campus Cologne-Merheim), Ostmerheimerstr. 200, 51109, Cologne, Germany.
authors.forename: Arne
authors.initials: A
authors.lastname: Driessen
authors.affiliation: Institute for Research in Operative Medicine (IFOM), Witten/Herdecke University (Campus Cologne-Merheim), Ostmerheimerstr. 200, 51109, Cologne, Germany.|Department of Orthopaedic Surgery, Traumatology and Sports Traumatology, Cologne-Merheim Medical Center (CMMC), Witten/Herdecke University (Campus Cologne-Merheim), Ostmerheimerstr. 200, 51109, Cologne, Germany.
authors.forename: Matthias
authors.initials: M
authors.lastname: Fröhlich
authors.affiliation: Institute for Research in Operative Medicine (IFOM), Witten/Herdecke University (Campus Cologne-Merheim), Ostmerheimerstr. 200, 51109, Cologne, Germany.
authors.forename: Ewa K
authors.initials: EK
authors.lastname: Stürmer
authors.affiliation: Institute for Research in Operative Medicine (IFOM), Witten/Herdecke University (Campus Cologne-Merheim), Ostmerheimerstr. 200, 51109, Cologne, Germany. marc.maegele@t-online.de.|Department of Orthopaedic Surgery, Traumatology and Sports Traumatology, Cologne-Merheim Medical Center (CMMC), Witten/Herdecke University (Campus Cologne-Merheim), Ostmerheimerstr. 200, 51109, Cologne, Germany. marc.maegele@t-online.de.
authors.forename: Marc
authors.initials: M
authors.lastname: Maegele
mesh_terms: D000465:Algorithms; D001778:Blood Coagulation Disorders / Q000209:etiology / Q000628:therapy; D001803:Blood Transfusion / Q000592:standards; D002985:Clinical Protocols; D005060:Europe; D006470:Hemorrhage / Q000175:diagnosis* / Q000628:therapy*; D006487:Hemostasis; D006801:Humans; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D012151:Resuscitation / Q000592:standards; D011795:Surveys and Questionnaires; D014193:Trauma Centers / Q000592:standards*