Haemotherapy algorithm for the management of trauma-induced coagulopathy: an Australian perspective.
OBJECTIVE
Recent advances in the understanding of the pathophysiological processes associated with traumatic haemorrhage and trauma-induced coagulopathy have resulted in improved outcomes for seriously injured trauma patients. However, a significant number of trauma patients still die from haemorrhage. This article reviews the various transfusion strategies utilized in the management of traumatic haemorrhage and describes the major haemorrhage protocol (MHP) strategy employed by an Australian trauma centre.


RESULTS
Few topics in trauma resuscitation incite as much debate and controversy as to what constitutes the 'ideal' MHP. There is a widespread geographical and institutional variation in clinical practice. Three strategies are commonly utilized; fixed ratio major haemorrhage protocol (FRMHP), viscoelastic haemostatic assay (VHA)-guided MHP and hybrid MHP. The majority of trauma centres utilize an FRMHP and there is high-level evidence to support the use of high blood product ratios. It can be argued that the FRMHP is too simplistic to be applied to all trauma patients and that the use of VHA-guided MHP with predominant factor concentrate transfusion can allow rapid individualized interventions. In between these two strategies is a hybrid MHP, combining early FRMHP with subsequent VHA-guided transfusion.


CONCLUSIONS
There are advantages and disadvantages to each of the various MHP strategies and the evidence base to support one above another with any certainty is lacking at this time. One strategy cannot be considered superior to the other and the choice of MHP is dependent on interpretation of the current literature and local institutional logistical considerations. A number of exciting studies are currently underway that will certainly increase the evidence base and help inform clinical practice.
aGold Coast University Hospital, Southport, Queensland bSchool of Medicine, University of Queensland, Brisbane, Queensland cSchool of Medical Sciences, Griffith University, Gold Coast, Queensland dIntensive Care Unit, Gold Coast University Hospital, Southport, Queensland eNational Trauma Research Institute fThe Alfred Hospital gDepartment of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria hJoint Health Command, Australian Defence Force iBurns, Trauma and Critical Care Research Centre, University of Queensland, Brisbane, Queensland jRoyal Brisbane and Women's Hospital, Herston, Queensland, Australia.
James
J
Winearls
Biswadev
B
Mitra
Michael C
MC
Reade
D001315:Australia; D001778:Blood Coagulation Disorders / Q000175:diagnosis* / Q000209:etiology / Q000401:mortality / Q000628:therapy; D001779:Blood Coagulation Factors / Q000502:physiology / Q000627:therapeutic use; D001780:Blood Coagulation Tests / Q000295:instrumentation* / Q000379:methods; D001803:Blood Transfusion / Q000379:methods / Q000592:standards*; D002985:Clinical Protocols; D055416:Evidence-Based Emergency Medicine / Q000379:methods; D005342:Fibrinolysis; D006470:Hemorrhage / Q000175:diagnosis / Q000209:etiology / Q000401:mortality / Q000628:therapy*; D006801:Humans; D019095:Point-of-Care Systems; D017410:Practice Guidelines as Topic; D012151:Resuscitation / Q000379:methods / Q000592:standards*; D014193:Trauma Centers / Q000592:standards / Q000639:trends; D016896:Treatment Outcome; D014947:Wounds and Injuries / Q000150:complications*
D001779:Blood Coagulation Factors