title: The European guideline on management of major bleeding and coagulopathy following trauma: fourth edition.
abstract: BACKGROUND
  Severe trauma continues to represent a global public health issue and mortality and morbidity in trauma patients remains substantial. A number of initiatives have aimed to provide guidance on the management of trauma patients. This document focuses on the management of major bleeding and coagulopathy following trauma and encourages adaptation of the guiding principles to each local situation and implementation within each institution.
  
  
  METHODS
  The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma was founded in 2004 and included representatives of six relevant European professional societies. The group used a structured, evidence-based consensus approach to address scientific queries that served as the basis for each recommendation and supporting rationale. Expert opinion and current clinical practice were also considered, particularly in areas in which randomised clinical trials have not or cannot be performed. Existing recommendations were reconsidered and revised based on new scientific evidence and observed shifts in clinical practice; new recommendations were formulated to reflect current clinical concerns and areas in which new research data have been generated. This guideline represents the fourth edition of a document first published in 2007 and updated in 2010 and 2013.
  
  
  RESULTS
  The guideline now recommends that patients be transferred directly to an appropriate trauma treatment centre and encourages use of a restricted volume replacement strategy during initial resuscitation. Best-practice use of blood products during further resuscitation continues to evolve and should be guided by a goal-directed strategy. The identification and management of patients pre-treated with anticoagulant agents continues to pose a real challenge, despite accumulating experience and awareness. The present guideline should be viewed as an educational aid to improve and standardise the care of the bleeding trauma patients across Europe and beyond. This document may also serve as a basis for local implementation. Furthermore, local quality and safety management systems need to be established to specifically assess key measures of bleeding control and outcome.
  
  
  CONCLUSIONS
  A multidisciplinary approach and adherence to evidence-based guidance are key to improving patient outcomes. The implementation of locally adapted treatment algorithms should strive to achieve measureable improvements in patient outcome.
authors.affiliation: Department of Anaesthesiology, University Hospital Aachen, RWTH Aachen University, Pauwelsstrasse 30, 52074, Aachen, Germany.
authors.forename: Rolf
authors.initials: R
authors.lastname: Rossaint
authors.affiliation: Department of Trauma and Orthopaedic Surgery, Witten/Herdecke University, Cologne-Merheim Medical Centre, Ostmerheimer Strasse 200, 51109, Cologne, Germany.
authors.forename: Bertil
authors.initials: B
authors.lastname: Bouillon
authors.affiliation: Department of Anaesthesiology, Perioperative Medicine and Intensive Care, J.E. Purkinje University, Masaryk Hospital, Usti nad Labem, Socialni pece 3316/12A, 40113, Usti nad Labem, Czech Republic.|Department of Research and Development, Charles University in Prague, Faculty of Medicine in Hradec Kralove, Sokolska 581, 50005, Hradec Kralove, Czech Republic.|Department of Anaesthesiology and Intensive Care, Charles University in Prague, Faculty of Medicine in Hradec Kralove, Sokolska 581, 50005, Hradec Kralove, Czech Republic.|Department of Anaesthesia, Pain Management and Perioperative Medicine, Dalhousie University, Halifax, QE II Health Sciences Centre, 10 West Victoria, 1276 South Park St., Halifax, NS, B3H 2Y9, Canada.
authors.forename: Vladimir
authors.initials: V
authors.lastname: Cerny
authors.affiliation: Emergency Medicine Academic Group, University of Leicester, University Road, Leicester, LE1 7RH, UK.
authors.forename: Timothy J
authors.initials: TJ
authors.lastname: Coats
authors.affiliation: Department of Anaesthesia and Intensive Care, Hôpitaux Universitaires Paris Sud, University of Paris XI, Faculté de Médecine Paris-Sud, 78 rue du Général Leclerc, 94275, Le Kremlin-Bicêtre, Cedex, France.
authors.forename: Jacques
authors.initials: J
authors.lastname: Duranteau
authors.affiliation: Servicio de Medicina Intensiva, Complejo Hospitalario Universitario de Granada, ctra de Jaén s/n, 18013, Granada, Spain.
authors.forename: Enrique
authors.initials: E
authors.lastname: Fernández-Mondéjar
authors.affiliation: Department of Cardiac Anaesthesia and Intensive Care, C. C. Iliescu Emergency Institute of Cardiovascular Diseases, Sos Fundeni 256-258, 022328, Bucharest, Romania.
authors.forename: Daniela
authors.initials: D
authors.lastname: Filipescu
authors.affiliation: King's College, Departments of Haematology, Pathology and Lupus, Guy's and St Thomas' NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH, UK.
authors.forename: Beverley J
authors.initials: BJ
authors.lastname: Hunt
authors.affiliation: Department of Traumatology, General and Teaching Hospital Celje, Oblakova 5, 3000, Celje, Slovenia.
authors.forename: Radko
authors.initials: R
authors.lastname: Komadina
authors.affiliation: Shock and Trauma Centre, S. Camillo Hospital, Viale Gianicolense 87, 00152, Rome, Italy.
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Nardi
authors.affiliation: Faculty of Health - School of Medicine, Witten/Herdecke University, Ostmerheimer Strasse 200, Building 38, 51109, Cologne, Germany.
authors.forename: Edmund A M
authors.initials: EA
authors.lastname: Neugebauer
authors.affiliation: Division of Anaesthesia, Intensive Care and Emergency Medicine, Brest University Hospital, Boulevard Tanguy Prigent, 29200, Brest, France.
authors.forename: Yves
authors.initials: Y
authors.lastname: Ozier
authors.affiliation: Department of Surgery and Trauma, Karolinska University Hospital, 171 76, Solna, Sweden.
authors.forename: Louis
authors.initials: L
authors.lastname: Riddez
authors.affiliation: Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, Lorenz Boehler Trauma Centre, Donaueschingenstrasse 13, 1200, Vienna, Austria.
authors.forename: Arthur
authors.initials: A
authors.lastname: Schultz
authors.affiliation: Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik 808, 1070, Brussels, Belgium.
authors.forename: Jean-Louis
authors.initials: JL
authors.lastname: Vincent
authors.affiliation: Institute of Anaesthesiology, University of Zurich and University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland. donat.spahn@usz.ch.
authors.forename: Donat R
authors.initials: DR
authors.lastname: Spahn
mesh_terms: D001778:Blood Coagulation Disorders / Q000628:therapy*; D019468:Disease Management; D004638:Emergency Treatment / Q000379:methods*; D005060:Europe; D019317:Evidence-Based Medicine / Q000379:methods; D017408:Guidelines as Topic; D006470:Hemorrhage / Q000628:therapy; D006801:Humans; D014947:Wounds and Injuries / Q000150:complications / Q000628:therapy