Abstract
Massive bleeding is a key issue in the treatment of trauma and surgery. It does in fact account for more than 50% of all trauma-related deaths within the first 48 h following hospital admission, and it can significantly raise the mortality rate of any kind of surgery. Despite this great clinical relevance, evidence on the management of massive bleeding is surprisingly scarce, and its treatment is often based on empirical grounds. Successful treatment of massive haemorrhage depends on better understanding of the associated physiological changes as well as on good team work between the different specialists involved in the management of such a complex condition. The aim of this article is to provide an overview of the pathophysiology as well as of current treatment options of such a condition, including the new concept of “damage control resuscitation”, which integrates permissive hypotension, haemostatic resuscitation and damage control surgery.
Similar content being viewed by others
References
Rossaint R, Bouillon B, Cerny V, Coats TJ, Duranteau J, Fernández-Mondéjar E et al (2010) Management of bleeding following major trauma: an updated European guideline. Crit Care 14:R52
Copeland GP, Jones D, Walters M (1991) POSSUM: a scoring system for surgical audit. Br J Surg 78:355–360
Sihler KC, Napolitano LM (2009) Massive transfusion. Chest 136:1654–1667
Hess JR, Brohi K, Dutton RP, Hauser CJ, Holcomb JB, Kluger Y, Mackway-Jones K, Parr MJ, Rizoli SB, Yukioka T, Hoyt DB, Bouillon B (2008) The coagulopathy of trauma: a review of mechanisms. J Trauma 65:748–754
Lier H, Krep H, Schroeder S, Stuber F (2008) Preconditions of hemostasis in trauma: a review. The influence of acidosis, hypocalcemia, anemia, and hypothermia on functional hemostasis in trauma. J Trauma 65:951–960
Maegele M (2009) Frequency, risk stratification and therapeutic management of acute post-traumatic coagulopathy. Vox Sang 97:39–49
Fenger-Eriksen C, Jensen TM, Kristensen BS, Jensen KM, Tønnesen E, Ingerslev J, Sørensen B (2009) Fibrinogen substitution improves whole blood clot firmness following dilution with hydroxyethyl starch in bleeding patients undergoing radical cystectomy: a randomised placebo-controlled clinical trial. J Thromb Haemost 7(5):795–802
Brummel-Ziedins K, Whelihan MF, Ziedins EG, Mann KG (2006) The resuscitative fluid you choose may potentiate bleeding. J Trauma 61:1350–1358
Meng ZH, Wolberg AS, Monroe DMI, Hoffman M (2003) The effect of temperature and pH on the activity of factor VIIa: implications for the efficacy of high-dose factor VIIa in hypothermic and acidotic patients. J Trauma 55:886–891
Raat NJ, Berends F, Verhoeven AJ, de Korte D, Ince C (2005) The age of stored red blood cell concentrates at the time of transfusion. Transfus Med 15:419–423
Martini WZ, Dubick MA, Pusateri AE, Park MS, Ryan KL, Holcomb JB (2006) Does bicarbonate correct coagulation function impaired by acidosis in swine? J Trauma 61:99–106
Martini WZ, Dubick MA, Wade CE, Holcomb JB (2007) Evaluation of tris-hydroxymethylaminomethane on reversing coagulation abnormalities caused by acidosis in pigs. Crit Care Med 35:1568–1574
Martini WZ (2009) Coagulopathy by hypothermia and acidosis: mechanisms of thrombin generation and fibrinogen availability. J Trauma 67:202–209
Turitto VT, Weiss HJ (1980) Red blood cells: their dual role in thrombus formation. Science 207:541–543
Valeri CR, Cassidy G, Pivacek LE et al (2001) Anemia-induced increase in the bleeding time: implications for treatment of nonsurgical blood loss. Transfusion 41:977–983
Levrat A, Gros A, Rugeri L, Inaba K, Floccard B, Negrier C, David J-S (2008) Evaluation of rotation thrombelastography for the diagnosis of hyperfibrinolysis in trauma patients. Br J Anaesth 100:792–797
Schöchl H, Frietsch T, Pavelka M, Jámbor C (2009) Hyperfibrinolysis after major trauma: differential diagnosis of lysis patterns and prognostic value of thrombelastometry. J Trauma 67:125–131
Hastbacka J, Pettila V (2003) Prevalence and predictive value of ionized hypocalcemia among critically ill patients. Acta Anaesthesiol Scand 47:1264–1269
British Committee for Standards in Haematology, Blood Transfusion Task Force (2004) Guidelines for the use of fresh-frozen plasma, cryoprecipitate and cryosupernatant. Br J Haematol 126:11–28
American Society of Anesthesiologists Task Force on Perioperative Blood Transfusion and Adjuvant Therapies (2006) Practice guidelines for perioperative blood transfusion and adjuvant therapies. Anesthesiology 105:198–208
British Committee for Standards in Haematology Writing Group, Stainsby D, MacLennan S, Thomas D, Isaac J, Hamilton PJ (2006) Guidelines on the management of massive blood loss. Br J Haematol 135:634–641
Toulon P, Ozier Y, Ankri A, Fléron M, Leroux G, Samama CM (2009) Point-of-care versus central laboratory coagulation testing during haemorrhagic surgery. A multicenter study. Thromb Haemost 101:394–401
Ganter MT, Hofer CK (2008) Coagulation monitoring: current techniques and clinical use of viscoelastic point-of-care coagulation devices. Anesth Analg 106:1366–1375
Plotkin AJ, Wade CE, Jenkins DH, Smith KA, Noe JC, Park MS, Perkins JG, Holcomb JB (2008) A reduction in clot formation rate and strength assessed by thrombelastography is indicative of transfusion requirements in patients with penetrating injuries. J Trauma 64:S64–S68
Jansen JO, Thomas R, Loudon MA, Brooks A (2009) Damage control resuscitation for patients with major trauma. BMJ 338:b1778
Busani S, Cavazzuti I, Marietta M, Pasetto A, Girardis M (2008) Strategies to control massive abdominal bleeding. Transplant Proc 40:1212–1215
Brohi K, Cohen MJ, Ganter MT, Schultz MJ, Levi M, Mackersie RC, Pittet JF (2008) Acute coagulopathy of trauma: hypoperfusion induces systemic anticoagulation and hyperfibrinolysis. J Trauma 64:1211–1217
Alam HB, Burris D, DaCorta JA et al (2005) Hemorrhage control in the battlefield: role of new hemostatic agents. Mil Med 170:63–69
Malone DL, Dunne J, Tracy JK, Putnam AT, Scalea TM, Napolitano LM (2003) Blood transfusion, independent of shock severity, is associated with worse outcome in trauma. J Trauma 54:898–907
Spannagl M, Schramm W (1999) Replacement of coagulation factors in liver or multiple organ dysfunction. Thromb Res 95:S51–S56
Johansson PI, Hansen MB, Sorensen H (2005) Transfusion practice in massively bleeding patients: time for a change? Vox Sang 89:92–96
Johansson PI, Stensballe J (2009) Effect of haemostatic control resuscitation on mortality in massively bleeding patients: a before and after study. Vox Sang 96:111–118
Hirshberg A, Dugas M, Banez EI et al (2003) Minimizing dilutional coagulopathy in exsanguinating hemorrhage: a computer simulation. J Trauma 54:454–463
Johansson PI, Stensballe J (2010) Hemostatic resuscitation for massive bleeding: the paradigm of plasma and platelets—a review of the current literature. Transfusion 50:701–710
Kashuk JL, Moore EE, Johnson JL, Haenel J, Wilson M, Moore JB, Cothren CC, Biffl WL, Banerjee A, Sauaia A (2008) Postinjury life threatening coagulopathy: is 1:1 fresh frozen plasma: packed red blood cells the answer? J Trauma 65:261–271
Scalea TM, Bochicchio KM, Lumpkins K et al (2008) Early aggressive use of fresh frozen plasma does not improve outcome in critically injured trauma patients. Ann Surg 248:578–584
Schols SEM, van der Meijden PEJ, van Oerle R, Curvers J, Heemskerk JWM, van Pampus ECM (2008) Increased thrombin generation and fibrinogen level after therapeutic plasma transfusion: relation to bleeding. Thromb Haemost 99:64–70
Gonzalez EA, Moore FA, Holcomb JH et al (2007) Fresh frozen plasma should be given earlier to patients requiring massive transfusion. J Trauma 62:112–119
Liumbruno GM, Sodini ML, Grazzini G (2008) Recommendations from the Tuscan transfusion system on the appropriate use of solvent/detergent-inactivated fresh-frozen plasma. Blood Transfus 6:25–36
Carless PA, Henry DA, Moxey AJ, O’Connell D, McClelland B, Henderson KM, Sly K, Laupacis A, Fergusson D (2004) Desmopressin for minimising perioperative allogeneic blood transfusion. Cochrane Database Syst Rev (1):Art. No.:CD001884
Crescenzi G, Landoni G, Biondi-Zoccai G, Pappalardo F, Nuzzi M, Bignami E, Fochi O, Maj G, Calabrò MG, Ranucci M, Zangrillo A (2008) Desmopressin reduces transfusion needs after surgery: a meta-analysis of randomized clinical trials. Anesthesiology 109:1063–1076
Coats T, Roberts I, Shakur H (2004) Antifibrinolytic drugs for acute traumatic injury. Cochrane Database Syst Rev (4):Art.No.:CD004896
Martinowitz U, Michaelson M (2005) Guidelines for the use of recombinant activated factor VII (rFVIIa) in uncontrolled bleeding: a report by the Israeli multidisciplinary rFVIIa task force. J Thromb Haemost 3:640–648
Boffard KD, Riou B, Warren B, Choong PI, Rizol S, Rossaint R, Axelsen M, Kluger Y, for the NovoSeven Trauma Study Group (2005) Recombinant factor VIIa as adjunctive therapy for bleeding control in severely injured trauma patients: two parallel randomized, placebo-controlled, double-blind clinical trials. J Trauma 59:8–18
Lin Y, Stanworth S, Birchall J, Doree C, Hyde C (2007) Recombinant factor VIIa for the prevention and treatment of bleeding in patients without haemophilia. Cochrane Database Syst Rev (2):Art.No.:CD005011
Velik-Salchner C, Haas T, Innerhofer P, Streif W, Nussbaumer W, Klingler A, Klima G, Martinowitz U, Fries D (2007) The effect of fibrinogen concentrate on thrombocytopenia. J Thromb Haemost 5:1019–1025
Charbit B, Mandelbrot L, Samain E, Baron G, Haddaoui B, Keita H, Sibony O, Mahieu-Caputo D, Hurtaud-Roux MF, Huisse MG, Denninger MH, de Prost D, for the PPH Study Group (2007) The decrease of fibrinogen is an early predictor of the severity of postpartum hemorrhage. J Thromb Haemost 5:266–273
Fenger-Eriksen C, Lindberg-Larsen M, Christensen AQ, Ingerslev J, Sørensen B (2008) Fibrinogen concentrate substitution therapy in patients with massive haemorrhage and low plasma fibrinogen concentrations. Br J Anaesth 101:769–773
Dempfle CE, Kälsch T, Elmas E, Suvajac N, Lücke T, Münch E, Borggrefe M (2008) Impact of fibrinogen concentration in severely ill patients on mechanical properties of whole blood clots. Blood Coagul Fibrinolysis 19:765–770
Dickneite G, Pragst I (2009) Prothrombin complex concentrate vs fresh frozen plasma for reversal of dilutional coagulopathy in a porcine trauma model. Br J Anaesth 102:345–354
Acknowledgments
The authors are indebted to Mrs. Gianna Sassi for the revision of the English text of the manuscript.
Conflict of interest
None.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Marietta, M., Pedrazzi, P., Girardis, M. et al. Posttraumatic massive bleeding: a challenging multidisciplinary task. Intern Emerg Med 5, 521–531 (2010). https://doi.org/10.1007/s11739-010-0396-3
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s11739-010-0396-3