Skip to main content
SpringerLink
Log in

Clinical Management of Severe Bleeding in Trauma Patients

  • Chapter
  • First Online:
Point-of-Care Tests for Severe Hemorrhage

  • 1309 Accesses

Abstract

Trauma is the leading cause of death between the ages of 1 year and 44 years and uncontrolled bleeding is the primary cause of these deaths. Coagulopathy is a frequent complication of haemorrhage and may occur in up to 25% of patients, even before hospital admission. While traditionally believed to be a result of iatrogenic causes such as dilution, hypothermia and acidosis, Trauma-Induced Coagulopathy (TIC) is now interpreted as amultifactorial global failure of the coagulation system to sustain adequate hemostasis after major trauma. Derangements in coagulation may occur soonafter a severe trauma, thus supporting the hypothesis of an early endogenous process. This acute coagulopathy, which occurs before and independent of iatrogenic reasons, is driven by the combination of tissue trauma and systemic hypoperfusion and characterized by global anticoagulation and hyperfibrinolysis together with a depletion of fibrinogen below levels currently recommended for therapeutic supplementation. In recent years, international guidelines have been developed aimed at preventing and treating trauma-induced coagulopathy.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Log in via an institution
eBook
USD 16.99
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD 109.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info
Hardcover Book
USD 159.99
Price excludes VAT (USA)
  • Durable hardcover edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

References

  1. Cohen MJ, Kutche MK, Redick B et al (2013) Clinical and mechanistic drivers of acute traumatic coagulopathy. J Trauma Acute Care Surg 75:S40–S47

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  2. Brohi K, Singh J, Heron M, Coats T (2003) Acute traumatic coagulopathy. J Trauma 54:1127–1130

    Article  PubMed  Google Scholar 

  3. Brohi K, Cohen MJ, Ganter MT et al (2008) Acute coagulopathy of trauma: hypoperfusion induces systemic anticoagulation and hyperfibrinolysis. J Trauma 64:1211–1217

    Article  PubMed  Google Scholar 

  4. Cohen MJ, Call M, Nelson M et al (2012) Critical role of activated Protein C in early coagulopathy and later organ failure, infection and death in trauma. Ann Surg 255:379–385

    Article  PubMed  PubMed Central  Google Scholar 

  5. Bolliger D, Gorlinger K, Tanaka KA (2010) Pathophysiology and treatment of coagulopathy in massive hemorrhage and hemodilution. Anesthesiology 113:1205–1219

    Article  PubMed  Google Scholar 

  6. Theusinger OM, Madjdpour C, Spahn D (2012) Resuscitation and transfusion management in trauma patients: emerging concepts. Curr Opin Crit Care 18:661–670

    Article  PubMed  Google Scholar 

  7. Jansen JO, Scarpelini S, Pinto R, Tien HC, Callum J, Rizoli SB (2011) Hypoperfusion in severely injured trauma patients is associated with reduced coagulation factor activity. J Trauma 71:S435–S440

    Article  CAS  PubMed  Google Scholar 

  8. Duchesne JC, McSwain NE Jr, Cotton BA et al (2010) Damage control resuscitation: the new face of damage control. J Trauma 69:976–990

    Article  PubMed  Google Scholar 

  9. Dirkmann D, Gorlinger K, Gisbertz C et al (2012) Factor XIII and tranexamic acid but not recombinant factor VIIa attenuate plasminogen activator-induced hyperfibrinolysis in human whole blood. Anesth Analg 114:1182–1188

    Article  CAS  PubMed  Google Scholar 

  10. Pham HP, Shaz BH (2013) Update on massive transfusion. Br J Anaesth 111:i71–i82

    Article  PubMed  Google Scholar 

  11. Maegele M, Lefering R, Paffrath T et al Working Group on Polytrauma of the German Society of Trauma Surgery (DGU) (2008) Red blood cell to plasma ratios transfused during massive transfusion are associated with mortality in severe multiply injury: a retrospective analysis from the Trauma Registry of the Deutsche Gesellschaft für Unfallschirurie. Vox Sang 95:112–119

    Google Scholar 

  12. 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

    Article  PubMed  Google Scholar 

  13. Cotton BA, Gunter OL, Isbell J et al (2008) Damage control hematology: the impact of a trauma exsanguination protocol on survival and blood product utilization. J Trauma 64:1177–1182

    Article  PubMed  Google Scholar 

  14. Gunter OL Jr, Au BK, Isbell JM, Mowery NT, Young PP, Cotton BA (2008) Optimizing outcomes in damage control resuscitation: identifying blood product ratios associated with improved survival. J Trauma 65:527–534

    Article  PubMed  Google Scholar 

  15. Magnotti LJ, Zarzaur BL, Fischer PE et al (2011) Improved survival after hemostatic resuscitation: does the emperor have no clothes? J Trauma 70:97–102

    Article  PubMed  Google Scholar 

  16. Patel SV, Kidane B, Klingel M, Parry N (2014) Risks associated with red blood cell transfusion in the trauma population, a meta-analysis. Injury 45:1522–1533

    Article  PubMed  Google Scholar 

  17. Spahn DR, Bouillon B, Cerny V et al (2013) Management of bleeding and coagulopathy following major trauma: an Updated European Guideline. Crit Care 17:R76

    Article  PubMed  PubMed Central  Google Scholar 

  18. Kozek-Langenecker S, Afshari A, Albaladejo P et al (2013) Management of severe perioperative bleeding. Guidelines from the European Society of Anaesthesiology. Eur J Anaesthesiol 30:270–382

    Article  PubMed  Google Scholar 

  19. Recommendations of the working group on Perioperative Coagulation of the ÖGARI: coagulation management in trauma-related massive bleeding. www.oegari.at

    Google Scholar 

  20. Yucel N, Lefering R, Maegele M (2006) Trauma associated severe hemorrhage (TASH)-Score: probability of mass transfusion as surrogate for life threatening hemorrhage after multiple trauma. J Trauma 60:1228–1236

    Article  PubMed  Google Scholar 

  21. Borgman MA, Spinella PC, Holcomb JB et al (2011) The effect of FFP: RBC ratio on morbidity and mortality in trauma patients based on transfusion prediction score. Vox Sang 101:44–54

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  22. Maegele M, Brockamp T, Nienaber U et al (2012) Predictive models and algorithms fort the need of transfusion including massive transfusion in severely injured patients. Transfus Med Hemother 39:85–97

    Article  PubMed  PubMed Central  Google Scholar 

  23. Brockamp T, Nienaber U, Mutschler M et al (2012) Predicting on-going hemorrhage and transfusion requirement after severe trauma: a validation of six scoring systems and algorithms on the Trauma Register DGU(R). Crit Care 16:R129

    Article  PubMed  PubMed Central  Google Scholar 

  24. Vandromme MJ, Griffin RL, McGwin G et al (2011) Prospective identification of patients at risk for massive transfusion: an imprecise endeavour. Am Surg 77:155–161

    PubMed  Google Scholar 

  25. Ives C, Inaba K, Branco BC et al (2012) Hyperfibrinolysis elicited via thromboelastography predicts mortality in trauma. J Am Coll Surg 215:496–502

    Article  PubMed  Google Scholar 

  26. Schochl H, Frietsch T, Pavelka M, Jambor C (2009) Hyperfibrinolysis after major trauma: differential diagnosis of lysis patterns and prognostic value of thrombelastometry. J Trauma 67:125–131

    Article  PubMed  Google Scholar 

  27. Shakur H, Roberts I, Bautista R et al (2010) Effects of tranexamic acid on death, vascular occlusive events and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomized, placebo – controlled trial. Lancet 376:23–32

    Article  CAS  PubMed  Google Scholar 

  28. Raza I, Davenport R, Rourke C et al (2013) The incidence and magnitude of fibrinolytic activation in trauma patients. Thromb Haemost 11:307–314

    Article  CAS  Google Scholar 

  29. The CRASH-2 Collaborators (2011) The importance of early treatment with tranexamic acid in bleeding trauma patients: an exploratory analysis of the CRASH-2 randomised controlled trial. Lancet 377:1096–1101

    Article  Google Scholar 

  30. Moore H, Moore E, Gonzalez E et al (2014) Hyperfibrinolysis, physiologic fibrinolysis, and fibrinolysis shutdown: The spectrum of postinjury fibrinolysis and relevance to antifibrinolytic therapy. J Trauma Acute Care Surg 77:811–817

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  31. Dossett LA, Riesel JN, Griffin MR, Cotton BA (2011) Prevalence and implications of preinjury warfarin use. An analysis of the National Trauma Databank. Arch Surg 146:565–570

    Article  PubMed  Google Scholar 

  32. Guyatt GH, Akl EA, Crowther M et al (2012) American College of Chest Physicians Antithrombotic Therapy and Prevention of Thrombosis Panel Executive Summary. ACCP Evidence Based Clinical Practice Guidelines (9th Edition). Chest 141:7S–47S

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  33. Holbrook A, Schulman S, Witt DM et al (2012) American College of Chest Physicians. Evidence-based management of anticoagulant therapy: antithrombotic therapy and prevention of thrombosis (9th Edition). Chest 141:e152S–e184S

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  34. Keeling D, Baglin T, Tait C et al (2011) British Committee for Standards in Hematology. Guidelines on oral anticoagulation with warfarin – fourth edition. Br J Haematol 154:311–324

    Article  PubMed  Google Scholar 

  35. Appelboam R, Thomas EO (2009) Warfarin and intracranial haemorrhage. Blood Rev 23:1–9

    Article  CAS  PubMed  Google Scholar 

  36. McMillian WD, Rogers FB (2009) Management of prehospital antiplatelet and anticoagulant therapy in traumatic head injury: a review. J Trauma 66:942–950

    Article  PubMed  Google Scholar 

  37. Chapmann SA, Irwin ED, Beal AL, Kulinski NM, Hutson KE, Thorson MA (2011) Prothrombin complex concentrate versus standard therapies for INR reversal in trauma patients receiving warfarin. Ann Pharmacother 45:869–875

    Article  Google Scholar 

  38. Imberti G, Barillari C, Biasioli M et al (2008) Prothrombin complex concentrate for urgent anticoagulation reversal in patients with intracranial haemorrhage. Pathophysiol Haemost Thromb 36:259–265

    Article  CAS  PubMed  Google Scholar 

  39. Pernod G, Godiér A, Gozalo C, Tremey B, Sié P, French National Authority for Health (2010) French clinical practice guidelines on the management of patients on vitamin K antagonists in at-risk situations (overdose, risk of bleeding, and active bleeding). Thrombosis Research 126:e167–e174

    Google Scholar 

  40. Prisco D (2005) Terapia anticoagulante orale, chirurgia e manovre invasive. Raccomandazioni della Federazione Centri per la Diagnosi della Trombosi e Sorveglianza della Terapie Antitrombotiche. Raccomandazioni FCSA. www.fcsa.it

  41. Weitz JI (2012) New oral anticoagulants: a review from the laboratory. Am J Hematol 87:S133–S136

    Article  CAS  PubMed  Google Scholar 

  42. Schulman S, Crowther MA (2012) How I treat with anticoagulants in 2012: new and old anticoagulants, and when and how to switch. Blood 119:3016–3023

    Article  CAS  PubMed  Google Scholar 

  43. Dzik WS (2012) Reversal of drug-induced anticoagulation: old solutions and new problems. Transfusion 52:45S–55S

    Article  CAS  PubMed  Google Scholar 

  44. Kaatz S, Kouides PA, Garcia DA et al (2012) Guidance on the emergent reversal of oral thrombin and factor Xa inhibitors. Am J Hematol 87:S141–S145

    Article  CAS  PubMed  Google Scholar 

  45. Pengo V, Crippa L, Falanga A et al (2011) Questions and answers on the use of dabigatran and perspectives on the use of other new oral anticoagulants in patients with atrial fibrillation. A consensus document of the Italian Federation of Thrombosis Centers (FCSA). Thromb Haemost 106:868–876

    Article  CAS  PubMed  Google Scholar 

  46. Batchelor JS, Grayson A (2012) A meta-analysis to determine the effect on survival of platelet transfusion in patients with either spontaneous or traumatic antiplatelet medication-associated haemorrhage. BMJ 2:e000588

    Article  Google Scholar 

  47. Washington CW, Schuerer DJ, Grubb R (2011) Platelet transfusion: an unnecessary risk for mild traumatic brain injury patients on antiplatelet therapy. J Trauma 71:358–363

    Article  PubMed  Google Scholar 

  48. Downey DM, Monson B, Butler KL et al (2009) Does platelet administration affect mortality in elderly head-injured patients taking antiplatelet medication? Am Surg 75:1100–1103

    PubMed  Google Scholar 

  49. Ivascu FA, Howells GA, Junn FS, Bair HA, Bendick PJ, Janczyk RJ (2008) Predictors of mortality in trauma patients with intracranial haemorrhage on pre-injury aspirin or clopidogrel. J Trauma 65:785–788

    Article  CAS  PubMed  Google Scholar 

  50. Fortuna GR, Mueller EW, James LE et al (2008) The impact of pre-injury antiplatelet and anticoagulant pharmacotherapy on outcomes in elderly patients with haemorrhagic brain injury. Surgery 144:598–603

    Article  PubMed  Google Scholar 

  51. Naidech AM, Liebling SM, Rosenberg NF et al (2012) Early platelet transfusion improves platelet activity and may improve outcomes for intracerebral haemorrhage. Neurocrit Care 16:82–87

    Article  PubMed  Google Scholar 

  52. Campbell PG, Sen A, Yadla S, Jabbour P, Jallo J (2010) Emergency reversal of antiplatelet agents in patients presenting with an intracranial haemorrhage: a clinical review. World Neurosurg 74:279–285

    Article  PubMed  Google Scholar 

  53. BCSH Guidelines for the use of platelet transfusions (2003) Br J Haematol 122:10–23. www.bcshguidelines.com

  54. Schlimp CJ, Voelckel W, Inaba K, Maegele M, Ponschab M, Schochl H (2013) Estimation of plasma fibrinogen levels based on hemoglobin, base excess and ISS upon emergency room admission. Crit Care 17:R137

    Article  PubMed  PubMed Central  Google Scholar 

  55. Rourke C, Curry N, Khan S et al (2012) Fibrinogen levels during trauma hemorrhage, response to replacement therapy and association with patient outcomes. J Thromb Haemost 10:1342–1351

    Article  CAS  PubMed  Google Scholar 

  56. Stinger HK, Spinella PC, Perkins JG et al (2008) The ratio of fibrinogen to red cells transfused affects survival in casualties receiving massive transfusions at an army combat support hospital. J Trauma 64:S79–S85

    Article  CAS  PubMed  Google Scholar 

  57. Spahn DR, Cerny V, Coats TJ et al (2007) Task Force for Advanced Bleeding Care in Trauma. Management of bleeding following major trauma: a European guideline. Crit Care 11:R17

    Article  PubMed  PubMed Central  Google Scholar 

  58. Borgman MA, Spinella PC, Perkins JG et al (2007) The ratio of blood products transfused affects mortality in patients receiving massive transfusions at a combat support hospital. J Trauma 63:805–813

    Article  PubMed  Google Scholar 

  59. Duchesne JC, Hunt JP, Wahl G et al (2008) Review of current blood transfusions strategies in a mature level I trauma center: were we wrong for the last 60 years? J Trauma 65:272–276

    Article  PubMed  Google Scholar 

  60. Savage SA, Zarzaur BL, Croce MA, Fabian TC (2014) Time matters in 1:1 resuscitations: concurrent administration of blood: plasma and risk of death. J Trauma Acute Care Surg 77:833–838

    Article  PubMed  Google Scholar 

  61. Snyder CW, Weinberg JA, McGwin G Jr et al (2009) The relationship of blood product ratio to mortality: survival benefit or survival bias? J Trauma 66:358–362

    Article  PubMed  Google Scholar 

  62. Ho AM, Dion PW, Yeung JH et al (2012) Prevalence of survivors bias in observational studies on fresh frozen plasma: erythrocyte ratios in trauma requiring massive transfusion. Anesthesiology 116:716–728

    Article  PubMed  Google Scholar 

  63. Brown JB, Cohen MJ, Minei JP et al (2012) Debunking the survival bias myth: characterization of mortality during the initial 24 hours for patients requiring massive transfusion. J Trauma Acute Care Surg 73:358–364

    Article  PubMed  Google Scholar 

  64. Khan S, Davemport R, Raza I et al (2015) Damage control resuscitation using blood component therapy in standard doses has a limited effect on coagulopathy during trauma hemorrhage. Int Care Med 41:239–247

    Article  CAS  Google Scholar 

  65. Baraniuk S, Tilley BC, del Junco DJ et al (2014) Pragmatic Randomized Optimal Platelet and Plasma Ratios (PROPPR) Trial: design, rationale and implementation. Injury 45:1287–1295

    Article  PubMed  PubMed Central  Google Scholar 

  66. Holcomb JB, Tilley BC, Baraniuk S et al (2015) Transfusion of plasma, platelets, and red blood cells in a 1:1:1 vs a 1:1:2 ratio and mortality in patients with severe trauma: the PROPPR randomized clinical trial. JAMA 313:471–482

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  67. Kelly JM, Callum JL, Rizoli SB (2013) 1:1:1-warranted or wasteful? Even where appropriate, high ratio transfusion protocols are costly: early transition to individualized care benefits patients and transfusion services. Expert Rev Hematol 6:631–633

    Article  CAS  PubMed  Google Scholar 

  68. Chowdury P, Saayman AG, Paulus U, Findlay GP, Collins PW (2004) Efficacy of standard dose and 30 ml/kg fresh frozen plasma in correcting laboratory parameters of haemostasis in critically ill patients. Br J Haematol 125:69–73

    Article  Google Scholar 

  69. Khan S, Brohi K, Chana M et al (2013) Hemostatic resuscitation is neither hemostatic nor resuscitative in trauma hemorrhage. J Trauma Acute Care Surg 76:561–568

    Article  Google Scholar 

  70. Inaba K, Branco BC, Rhee P et al (2010) Impact of plasma transfusion in trauma patients who do not require massive transfusion. J Am Coll Surg 210:957–965

    Article  PubMed  Google Scholar 

  71. Pandey S, Vyas GN (2012) Adverse affects of plasma transfusion. Transfusion 52:65S–79S

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  72. Johnson JL, Moore EE, Kashuk JL et al (2010) Effect of blood products transfusion on the development of postinjury multiple organ failure. Arch Surg 145:973–977

    Article  PubMed  Google Scholar 

  73. Hess RJ (2013) Resuscitation of trauma induced coagulopathy. In: American Society of Hemathology, p 664–667

    Google Scholar 

  74. Fries D, Innerhofer P, Perger P et al (2010) Coagulation management in trauma-related massive bleeding. Recommendations of the Task Force for Coagulation (AGPG) of the Austrian Society of Anesthesiology, Resuscitation and Intensive Care Medicine (OGARI). Anasthesiol Intensivmed Notfallmed Schmerzther 45:552–561

    Article  PubMed  Google Scholar 

  75. Schöchl H, Nienaber U, Hofer G et al (2010) Goal-directed coagulation management of major trauma patients using thromboelastometry (ROTEM)-guided administration of fibrinogen concentrate and prothrombin complex concentrate. Crit Care 14:R55

    Article  PubMed  PubMed Central  Google Scholar 

  76. Nienaber U, Innerhofer P, Westermann I et al (2011) The impact of fresh frozen plasma vs coagulation factors concentrates on morbidity and mortality in trauma-associated haemorrhage and massive transfusion. Injury 42:697–701

    Article  PubMed  Google Scholar 

  77. Theusinger OM, Wanner GA, Emmert MY et al (2011) Hyperfibrinolisis diagnosed by rotational thromboelastometry (ROTEM) is associated with higher mortality in patients with severe trauma. Anesth Analg 113:1003–1012

    Article  PubMed  Google Scholar 

  78. Haas T, Görlinger K, Grassetto A (2014) Thomboelastometry for guiding bleeding management of the critically ill patient: a systematic review of the literature. Minerva Anestesiol 80:1–16

    Google Scholar 

  79. Da Luz LT, Nascimento B, Shankarakutty AK, Rizoli S, Adhikar NKJ (2014) Effect of thromboelastography (TEG®) and rotational thromboelastometry (ROTEM®) on diagnosis of coagulopathy, transfusion guidance and mortality in trauma: descriptive systematic review. Crit Care 18:R518

    Article  Google Scholar 

  80. Winsted D, Thomas OD, Nisson F, Olanders K, Schött U (2014) Correction of hypothermic and dilutional coagulopathy with concentrates of fibrinogen and factor XIII: an in vitro study with ROTEM. Scand J Trauma Resusc Emerg Med 22:73

    Article  Google Scholar 

  81. Görlinger K, Fries D, Dikmann D, Weber C, Hanke AA, Schöchl H (2012) Reduction of fresh frozen plasma requirements by perioperative point-of care coagulation management with early calculated goal-directed therapy. Transfus Med Hemother 39:104–113

    Article  PubMed  PubMed Central  Google Scholar 

  82. Wikkelsø A, Lunde J, Johansen M (2013) Fibrinogen concentrate in bleeding patients (Review). Cochrane Database of Syst Rev 8:CD008864

    Google Scholar 

  83. Nardi G, Agostini V, Rondinelli MB et al (2013) Prevention and treatment of Trauma Induced Coagulopathy (TIC). An intended protocol from the Italian Trauma Update Research Group. J Anesthesiol Clin Sci www.hoajonline.com/jacs/2049-9752/2/22 (http://dx.doi.org/10.7243/2049-9752-2-22)

  84. Sarode R (2012) How do I transfuse platelets (PLTS) to reverse anti-PLT drug effect. Transfusion 52:695–701

    Article  CAS  PubMed  Google Scholar 

  85. Vilahur G, Choi BG, Zafar MU et al (2007) Normalization of platelet reactivity in clopidogrel-treated subjects. J Thromb Haemost 5:82–90

    Article  CAS  PubMed  Google Scholar 

  86. Tosetto A, Balduini CL, Cattaneo M (2009) Management of bleeding and for invasive procedures in patients with platelet disorders and/or thrombocytopenia: Guidelines of the Italian Society for haemostasis and Throbosis (SISET). Thromb Res 124:e13–e18

    Article  CAS  PubMed  Google Scholar 

  87. James MF, Michell WL, Joubert IA et al (2011) Resuscitation with hydroxyethil starch improves renal function and lactate clearance in penetrating trauma in a randomized controlled study: the FIRST trial (Fluids Resuscitation of Severe Trauma). Br J Anaesth 107:693–702

    Article  CAS  PubMed  Google Scholar 

  88. Nardi G, Agostini V, Rondinelli MB et al (2015) Trauma induced coagulopathy: impact of the early coagulation support protocol on blood product consumption, mortality and costs. Crit Care 19:83

    Article  PubMed  PubMed Central  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Shock and Trauma Center, S. Camillo-Forlanini Hospital, Roma, Italy

    Giuseppe Nardi MD & Emiliano Cingolani MD

  2. Transfusion Medicine Cesena/Forlì and Blood Establishment, Clinical Pathology Department-Cesena Azienda U.S.L Romagna, Romagna, Italy

    Vanessa Agostini MD

  3. UOC Anestesia e Rianimazione, Dipartimento Emergenza Urgenza, Ospedale dell’Angelo di Mestre, Venice, Italy

    Alberto Grassetto MD

  4. U.O.C. Anesthesia and Intensive Care, M.Rummo Hospital, Benevento, Italy

    Concetta Pellegrini MD

Authors
  1. Giuseppe Nardi MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Vanessa Agostini MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Alberto Grassetto MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Emiliano Cingolani MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Concetta Pellegrini MD
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Giuseppe Nardi MD .

Editor information

Editors and Affiliations

  1. Department of Anaesthesia and Intensive Care, IRCCS Policlinico San Donato, San Donato Milanese, Italy

    Marco Ranucci

  2. Department of Medicine Hemorrhagic and Thrombotic Diseases Unit, University of Padua Medical School, Padua, Italy

    Paolo Simioni

Rights and permissions

Reprints and permissions

Copyright information

© 2016 Springer International Publishing Switzerland

About this chapter

Cite this chapter

Nardi, G., Agostini, V., Grassetto, A., Cingolani, E., Pellegrini, C. (2016). Clinical Management of Severe Bleeding in Trauma Patients. In: Ranucci, M., Simioni, P. (eds) Point-of-Care Tests for Severe Hemorrhage. Springer, Cham. https://doi.org/10.1007/978-3-319-24795-3_7

Download citation

  • DOI: https://doi.org/10.1007/978-3-319-24795-3_7

  • Published:

  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-319-24793-9

  • Online ISBN: 978-3-319-24795-3

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics

Search

Navigation