THE MANAGEMENT OF MASSIVE BLEEDING IN POLYTRAUMA PATIENTS

- Executive Summary

This guideline provides standardized, evidence‑based recommendations for the recognition and management of massive bleeding in trauma patients.

Key Principles

Early Recognition & Immediate Control: Rapid identification of haemorrhage and prompt surgical or interventional bleeding control is essential.
Damage Control Resuscitation (DCR): Adopted globally over the past decade, DCR emphasizes:

Permissive hypotension until bleeding is controlled.
Balanced blood‑product transfusion (plasma, platelets, red cells).
Restricted crystalloid use to avoid dilutional coagulopathy.
Early correction of coagulopathy.

Multidisciplinary Approach: Integration of emergency medicine, surgery, anaesthesia, and intensive care teams to deliver coordinated haemostatic resuscitation tailored to patient physiology.

1. Minimize Time to Bleeding Control

We recommend that the time between injury and bleeding control be minimized. (Strong recommendation)

2. Local Compression of Open Wounds

We recommend local compression of open wounds to limit life-threatening bleeding. (Strong recommendation)

3. Tourniquet Use for Extremity Injuries

We recommend adjunct tourniquet use to stop life-threatening bleeding from open extremity injuries in the pre-surgical setting. (Strong recommendation)

4. Follow the C-ABCDE Approach

We recommend Following the C-ABCDE approach in the management of polytraumatized patients with massive bleeding. (Strong recommendation)

5. Clinical Assessment of Traumatic Haemorrhage

We recommend that the physician should clinically assess the extent of traumatic hemorrhage using a combination of patient vital signs, anatomical injury pattern, mechanism of injury and the patient response to initial resuscitation. (Strong recommendation)

6. Use of Shock Index (SI) and narrowed pulse pressure (PP)

We recommend that the Shock Index (SI) and/or Pulse Pressure (PP) be used to assess the degree of hypovolemic shock and transfusion requirements. (Strong recommendation)

7. Immediate Bleeding Control

We recommend that patients with an obvious bleeding source and those presenting with haemorrhagic shock in extremities and a suspected source of bleeding undergo an immediate bleeding control procedure, if not available transfer patient to the nearest appropriate facility after stabilization. (Strong recommendation)

8. Investigation of Unidentified Bleeding Source

We recommend that patients with an unidentified source of bleeding should undergo immediate further investigation to determine the bleeding source.
(Strong recommendation)

9. Use of Point-of-Care Ultrasonography (POCUS)

We suggest the use of point-of-care ultrasonography (POCUS), including eFAST, in patients with thoracoabdominal injuries if feasible (Conditional recommendation)

10. Early Whole-Body CT (WBCT)

We suggest early imaging using contrast-enhanced whole-body CT (WBCT) for detection and identification of injury type and bleeding source after patient stabilization, if available. (Conditional recommendation)

11. Repeated Haemoglobin/Haematocrit Monitoring

during resuscitation, we recommend repeating Hb and/or Hct measurements within 30 – 60 minutes, as initial normal values may mask early bleeding. (Strong recommendation)

12. Lactate and Base Deficit Monitoring

We suggest measurement of blood lactate as a sensitive test to estimate and monitor the extent of bleeding and tissue hypoperfusion; In the absence of lactate measurements, base deficit may represent a suitable alternative. If available. (Conditional recommendation)

13. Monitoring of Haemostasis

We recommend the early and repeated monitoring of haemostasis, using an international normalised ratio (INR), and platelet count. (Strong recommendation)

14. Restricted Volume Replacement and Blood Pressure Targets

We recommend the use of a restricted volume replacement strategy in the absence of clinical evidence of brain injury with a target systolic blood pressure of 80–90 mmHg (mean arterial pressure 50–60 mmHg) In the initial phase following trauma, until major bleeding has been stopped. (Strong recommendation)

15. In patients with severe TBI (GCS ≤ 8)

we recommend maintaining mean arterial pressure ≥ 80 mmHg. (Strong recommendation)

16. Use of Noradrenaline When Restricted Volume Replacement Fails

we recommend the administration of noradrenaline to maintain target arterial blood pressure, if a restricted volume replacement strategy does not achieve the target blood pressure. (Strong recommendation)

17. Choice of Crystalloid Solutions

We recommend that fluid therapy using a 0.9% sodium chloride and/or ringer lactate or balanced crystalloid solution be initiated in the hypotensive bleeding trauma patient. (Strong recommendation)

18. Avoidance of Hypotonic Solutions in TBI

We recommend against hypotonic solutions during resuscitation of patients with haemorrhagic shock and traumatic brain injury. (Strong recommendation)

19. Restriction of Colloid Use

We suggest restricting the use of colloids due to their adverse effects on haemostasis. (Conditional recommendation)

20. Target Haemoglobin After Bleeding Control

We recommend a target haemoglobin of 7–9 g/dL after controlling the source of bleeding. (Strong recommendation)

21. Prevention and Management of Hypothermia

We recommend early application of measures such covering the patient and warm fluids to reduce heat loss and warm the hypothermic patient to achieve and maintain normothermia. (Strong recommendation)

22. Damage Control Surgery

We suggest damage control surgery in the severely injured patient if the definitive surgery to control the source of bleeding is complicated and time-consuming (>90 minutes) in the presence of severe persistent coagulopathy, severe acidosis with base deficit >15 mmol/L or lactate >5 mmol/L, hypothermia <34°C, or signs of ongoing bleeding despite the initial attempts of bleeding control with systolic BP persistently <90 mmHg. (Conditional recommendation)

23. Pelvic Binder Use

We recommend the adjunct use of a pelvic binder or pelvic sheet to limit life threatening bleeding in the presence of a suspected pelvic fracture. (Strong recommendation)

24. Topical Haemostatic Agents

We suggest the use of topical haemostatic agents with packing for venous or moderate arterial bleeding associated with parenchymal injuries. (Conditional recommendation)

25. Tranexamic Acid (TXA)

We recommend TXA administration in trauma patients who are bleeding or at risk of significant bleeding, as soon as possible and within 3 hours of injury at a loading dose of 1 g IV over 10 min, followed by 1 g IV infusion over 8 h.
(Strong recommendation)

26. Balanced Blood Product Transfusion

We recommend transfusion of pRBCs: FFP: Platelets in ratio following the massive transfusion protocols, In the initial management of patients with suspected massive haemorrhage. (Strong recommendation)

27. Calcium Monitoring and Supplementation

We recommend that ionised calcium levels be monitored and maintained within the normal range following major trauma and especially during massive transfusion. We recommend the administration of calcium to correct hypocalcaemia. (Strong recommendation)

28. Reversal of Vitamin K Antagonists (VKA)

We recommend the emergency reversal of vitamin K-dependent oral anticoagulants in the bleeding trauma patient with the early use of 5–10 mg I.V. phytomenadione (vitamin K1) in addition to FFP. (Strong recommendation)