THE MANAGEMENT OF MASSIVE BLEEDING IN POLYTRAUMA PATIENTS

1. Minimize Time to Bleeding Control

We recommend that the time between injury and bleeding control be minimized.

Strength of recommendation: Strong
Level of evidence: Moderate

Rationale:

Trauma Systems and the Chronology of Care
​Regionalization and Trauma System Maturity

​The implementation of regionalized trauma systems has fundamentally improved outcomes for severely injured patients globally. These systems utilize a tiered network of designated trauma centers (Levels I through IV) that collaborate with pre-hospital Emergency Medical Services (EMS). A meta-analysis of over 1.1 million patients confirmed that the establishment of such systems significantly reduces mortality, with survival rates continuing to climb as these systems mature and integrate quality improvement programs and trauma registries [8].

​Evidence from multicenter cohort studies indicates that patients in hemorrhagic shock (SBP < 90 mmHg) have significantly higher survival rates when treated at Level I Trauma Centers compared to Level III or IV facilities [9].

This underscores the necessity of a systemized approach that matches patient acuity to the appropriate facility based on vital status, injury patterns, and available hospital resources.

​The Impact of Time on Survival

​Uncontrolled hemorrhage is the leading cause of potentially preventable trauma deaths, with data suggesting that approximately 34.5% of early hemorrhagic fatalities could be avoided through more rapid bleeding control [10].

​Pre-Hospital Time Factors

​Time lost during the pre-hospital phase is directly linked to increased mortality. Extensive analyses of EMS data demonstrate that:

• ​Penetrating Trauma: Every additional minute of response time correlates with a 2% increase in mortality, while every extra minute spent on the scene correlates with a 1% increase [11, 12].
• ​Hemodynamic Instability: For unstable patients, particularly those with penetrating injuries, "scoop and run" strategies (minimizing scene time) are significantly more beneficial than prolonged on-scene stabilization [13].
• ​Functional Outcomes: Even in hemodynamically stable patients where mortality might not be immediately affected by time, longer pre-hospital durations are associated with an increased risk of poor long-term functional recovery [14].

​In-Hospital Delay: "Door-to-Needle"

​The mandate to minimize time-to-intervention extends beyond the hospital doors. For patients with ongoing hemorrhage, "door-to-intervention" time—whether for surgery or angioembolization is a critical survival factor [15, 16].

Delays in initiating these procedures are associated with worsened outcomes, reinforcing that both swift pre-hospital transport and streamlined in-hospital trauma protocols are essential to patient salvage.

2. Local Compression of Open Wounds

We recommend local compression of open wounds to limit life-threatening bleeding.

Strength of recommendation: Strong
Level of evidence: Moderate

Rationale:

Local Haemorrhage Control Techniques

​In civilian trauma, most life-threatening hemorrhages resulting from open extremity injuries can be managed effectively through local compression. This is typically achieved via direct manual pressure or the application of specialized pressure dressings to the site of injury [17].

​Additional compression to the source of bleeding can also be achieved for some penetrating injuries by Foley catheter inserting directly into the wound, initially described in bleeding penetrating neck injuries. [18].

Furthermore, the efficacy of external hemorrhage control in pre-hospital environments is significantly enhanced using compression bandages impregnated with or used in conjunction with topical hemostatic agents [19].

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.

Strength of recommendation: Strong
Level of evidence: Moderate

Rationale:

Rationale for Tourniquet Application

​In cases of catastrophic extremity trauma, such as traumatic amputations or deep penetrating injuries, manual direct pressure may be insufficient to achieve definitive hemostasis. For these life-threatening scenarios, the application of a tourniquet is a critical, life-saving intervention [19].

​Originally validated in military medicine where it has saved numerous lives, the efficacy of tourniquets is now strongly supported by civilian data demonstrating a significant decrease in hemorrhage-related mortality [19–22].

​While potential complications—such as nerve injury or localized tissue damage have been documented, these risks are statistically rare and are heavily outweighed by the immediate necessity of preventing exsanguination [23–25].

A tourniquet acts as a vital bridge, controlling the bleeding just long enough to get the patient to definitive surgical care."[19].

 

4. Follow the C-ABCDE Approach

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

Strength of recommendation: Strong
Level of evidence: Low

Rationale:

The <C>ABCDE Paradigm

​In the acute management of severe trauma, the most immediate threat to patient survival is exsanguination from catastrophic hemorrhage, which can lead to death within minutes. Consequently, the traditional "ABCDE" resuscitation sequence has been refined to the "<C>ABCDE" framework [26].

​By prioritizing "<C>" (Catastrophic External Hemorrhage) at the start of the primary survey, clinicians are directed to achieve definitive bleeding control even before addressing airway management. This fundamental shift in trauma priority ensures that the most time-critical physiological threat is mitigated immediately, thereby enhancing the efficacy of subsequent resuscitation and stabilization efforts [26, 27].

 

5. Clinical Assessment of Traumatic Haemorrhage

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

Strength of recommendation: Strong
Level of evidence: Low

Rationale:

Assessment and Prediction of Traumatic Haemorrhage
​Limitations of Traditional Assessment and Scoring Systems

​Although the current ATLS classification system for hypovolemic shock incorporates physiological markers like base excess to estimate blood loss and transfusion requirements, its precision remains a subject of clinical debate [26, 27].

While numerous predictive models and clinical scores have been engineered to forecast hemorrhage, traumatic coagulopathy, or the necessity for Massive Transfusion (MT), their performance is inconsistent. Reported Area Under the Receiver Operating Characteristics (AUROC) values range widely from 0.73 to 0.95, and a lack of robust prospective validation has prevented any single tool from achieving universal clinical adoption [28].

​A meta-analysis of 84 studies identified 35 distinct predictive variables, with systolic blood pressure (SBP), age, heart rate, and injury mechanism being the most frequently scrutinized [28].

However, methodological rigor varies; of the 47 multivariate models analyzed, only 21 adhered to the standard of 10 events per predictor. The most reliable variables identified across multiple models include:

• ​Mechanism of injury
• ​Systolic Blood Pressure (SBP) and Heart Rate
• ​Haemoglobin and Lactate levels
• ​Focused Assessment with Sonography in Trauma (FAST) findings [28].

​The Role of Injury Mechanism and Critical Haemorrhage

​Evaluating the mechanism of trauma is essential for accurate risk stratification. A fall exceeding the "critical height" of 6 meters (20 feet) is strongly correlated with major internal injuries and significant blood loss [29].

Furthermore, patients who are physically trapped following an incident often present with time-critical injuries that demand immediate intervention due to the high probability of occult hemorrhage [30].

​Other high-risk mechanisms include high-energy deceleration impacts and wounds from high-velocity projectiles. Notably, modern clinical shifts toward low-volume resuscitation and permissive hypotension have changed how practitioners interpret a patient’s physiological response to fluid challenges, making traditional assessment even more complex.

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.

Strength of recommendation: Strong
Level of evidence: Low

Rationale:

Predictive Value of Physiological Ratios
​Shock Index (SI)

​The Shock Index (SI), defined as the ratio of heart rate to systolic blood pressure, serves as a robust predictor of occult hemorrhage. While a normal SI in healthy adults it ranges from 0.5 to 0.7, retrospective data indicates that values between 0.9 and 1.0 are associated with a 25% requirement for Massive Transfusion (MT), a 14.7% need for surgical intervention, and a 6.2% requirement for interventional radiology [31].

​Across various retrospective studies, thresholds between 0.8 and 1.0 have consistently predicted the need for MT, yielding AUROC values between 0.73 and 0.89 [32–35].

 Prospective analysis of 1,402 patients suggested that an SI of 0.8 provides higher sensitivity than 0.9 [32].

Specifically, a cut-off of 0.81 demonstrated 85% sensitivity and a 98% negative predictive value for MT [36], while a threshold of 0.91 achieved 81% sensitivity and 87% specificity [35].

​Even after adjusting for age, sex, and injury severity (ISS/GCS), the SI remains an independent predictor for mortality and transfusion requirements (OR 3.57) [36].

Notably, an SI of 1.0 has been shown to outperform the ABC score in predicting MT and is more effective than simple hypotension in identifying patients requiring emergency operative intervention [33, 37].

​Pulse Pressure (PP)

​A narrowed Pulse Pressure (PP) the difference between systolic and diastolic blood pressure is a recognized hallmark of Class II hemorrhage according to ATLS guidelines. Current literature defines a narrow PP as less than 40 mmHg, or in some clinical contexts, less than 30 mmHg.

​Evidence confirms that a narrowed PP is independently linked to an increased likelihood of requiring blood transfusions, resuscitative thoracotomy, and emergent surgical control of bleeding [38–40].

Multivariate analyses further substantiate this, revealing that a PP below 30 mmHg is a significant predictor for both MT (OR 3.74) and the necessity for immediate operative intervention [41].

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.

Strength of recommendation: Strong
Level of evidence: Moderate

Rationale:

Rationale for Immediate Surgical Intervention

​Patients presenting in profound hemorrhagic shock have typically sustained critical blood loss. In "agonal" patients where active hemorrhage persists, mortality is imminent unless the source of bleeding is controlled with extreme urgency.

​Evidence from a study of 271 patients undergoing immediate laparotomy for gunshot wounds indicates that the combination of penetrating trauma and severe hypovolemic shock necessitates rapid, definitive surgical hemostasis [42].

Furthermore, a large-scale analysis of 16,113 trauma admissions identified a specific subset of 628 patients requiring "direct-to-operating-room" resuscitation. This study concluded that the most accurate predictors for the necessity of immediate surgical intervention include:

• ​Mechanism of Injury: Penetrating truncal trauma.
• ​Anatomical/Physical Findings: Traumatic amputations or other obvious major vascular disruptions.
• ​Physiological Derangement: Profound shock (systolic blood pressure < 90 mmHg) or a requirement for pre-hospital CPR [43].

​Ultimately, for patients meeting these criteria, bypassing the traditional emergency department workup in favor of direct operative resuscitation optimizes outcomes when every minute is critical to survival [43].

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.
Strength of recommendation: Strong
Level of evidence: Low

Rationale:

Diagnostic Evaluation of the Stabilized Patient

​For trauma patients who remain hemodynamically stable or achieve stabilization during initial resuscitation, a systematic diagnostic investigation is required to identify occult sources of hemorrhage. In cases where immediate surgical control is not indicated, the primary survey should be augmented with laboratory analysis—specifically blood gas and coagulation profiles and advanced imaging modalities, including ultrasonography and Computed Tomography (CT) [26, 44].

​The Evolution of Trauma Imaging

​In modern trauma care, the widespread accessibility of CT scanners has largely superseded traditional radiographic imaging for the definitive assessment of internal injuries [45].

Research indicates that the physical proximity of the CT scanner to the resuscitation bay significantly improves survival probabilities for severely injured patients by minimizing transport times and delays in diagnosis [46].

​Whole-Body CT in Unstable Patients

​When a CT scanner is located outside the emergency department, clinicians must carefully weigh the diagnostic benefits of imaging against the risks associated with transporting a critically ill patient. Continuous monitoring and ongoing resuscitation must be maintained throughout the transfer process. However, evidence suggests that within a well-structured environment and a highly organized trauma team, whole-body CT (WBCT) is both safe and clinically justified, even in the management of hemodynamically unstable patients [47].

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

We advise the use of point-of-care ultrasonography (POCUS), including eFAST, in patients with thoracoabdominal injuries IF FEASIABLE

Strength of recommendation: Conditional
Level of evidence: Low

Rationale:

The Role of Point-of-Care Ultrasound (POCUS)
​Pre-hospital Ultrasound (PHUS)

​The diagnostic accuracy of pre-hospital ultrasound (PHUS) is considered adequate for identifying pneumothorax, free intra-abdominal fluid, and hemoperitoneum. A systematic review involving 2,889 trauma patients demonstrated high sensitivity and specificity, with several studies noting that PHUS findings led to direct changes in clinical management [48].

 While a more recent review of 3,317 patients confirmed the feasibility of PHUS and its impact on transport decisions, significant inconsistencies in protocols and outcome measures currently prevent a formal meta-analysis of its global efficacy [49].

​In-Hospital POCUS and the FAST Protocol

​In the hospital setting, the Focused Assessment with Sonography in Trauma (FAST) remains a cornerstone of the primary ATLS survey for detecting hemorrhage in the plural, pericardial, and peritoneal cavities [50].

​While FAST exhibits high specificity (0.96), its sensitivity is variable (0.74), often depending on the patient population and the anatomical region affected [50]. Notably, a negative FAST examination cannot definitively exclude internal injury and must be validated against a reference standard, such as CT, especially in symptomatic patients.

​This limitation is particularly critical in hemodynamically unstable patients. An analysis of the PROMMTT trial revealed that nearly 7% of hypotensive patients with a negative FAST still required a laparotomy within six hours of admission [51].

Consequently, in the presence of unexplained hypotension, significant intra-abdominal hemorrhage must be suspected regardless of ultrasound findings [51].

​Advanced Techniques and Regional Accuracy

​POCUS appears to yield higher diagnostic sensitivity for thoracic and cardiac injuries compared to abdominal assessments [50, 52, 53].

To improve the utility of ultrasound in trauma, several specialized techniques have been proposed:

• ​FAST-PLUS Protocol: Incorporating a transverse scan of the pubic symphysis can identify unstable pelvic fractures with high correlation to CT findings [54].
• ​Patient Positioning: Rolling a patient to the right lateral position during the exam may increase sensitivity by shifting fluid into more visible acoustic windows, potentially converting false-negative results into true positives [55].

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.
Strength of recommendation: Conditional
Level of evidence: Moderate

Rationale:

Efficacy of Whole-Body Computed Tomography (WBCT)
​Diagnostic Accuracy and Clinical Utility

​Observational and retrospective evidence consistently supports the use of Whole-Body Computed Tomography (WBCT) for its superior diagnostic accuracy, time-saving capabilities, and ability to localize hemorrhage sources rapidly [45, 56].

In multicenter studies, CT has demonstrated 100% sensitivity for identifying retroperitoneal hematomas and intra-abdominal injuries in patients presenting with the "seat belt sign" (abrasions or ecchymosis) [57, 58].

​Evidence from the REACT-2 Trial

​The REACT-2 trial, the only prospective randomized controlled trial (RCT) in this field, compared immediate WBCT to conventional selective CT. While the trial found no significant survival difference between the two groups for general polytrauma or traumatic brain injury (TBI) [59], a secondary analysis yielded critical insights for bleeding patients. For the subset of patients requiring emergency hemorrhage control, immediate WBCT was associated with an absolute risk reduction in mortality of 11.2% [60].

​Time-Critical Outcomes

​The implementation of WBCT significantly reduces the total time spent in the emergency department [61].

Furthermore, evidence suggests a direct correlation between the speed of imaging and survival; a median time of 19 minutes from hospital admission to CT has been significantly associated with a decrease in mortality caused by exsanguination [62].

​Refined Clinical Criteria

​Based on secondary data from the REACT-2 study, a set of 10 clinical criteria with high positive predictive value for severe injury has been developed to assist in identifying candidates for immediate WBCT [63].

However, practitioners should note that these criteria are derived from post hoc analyses and may not be universally applicable. A targeted diagnostic approach is often warranted, as hemodynamic instability can occasionally impair the sensitivity of contrast-enhanced CT in detecting active extravasation [64].

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.
Strength of recommendation: Strong
Level of evidence: Moderate

Rationale:

Haemoglobin and Haematocrit Monitoring
​Limitations of Initial Measurements

​In the acute phase of trauma, a single, baseline hemoglobin (Hb) measurement is often an unreliable indicator of the extent of blood loss. This diagnostic limitation stems from the physiological lag in fluid equilibration and the confounding effects of early crystalloid resuscitation, which may artificially dilute or temporarily mask the severity of the hemorrhage [66, 72].

Because initial Hb levels often remain within the normal range during the early stages of catastrophic bleeding, relying solely on admission values can lead to a dangerous underestimation of injury severity [73, 74].

​Serial Monitoring and Emerging Technologies

​Current evidence emphasizes the necessity of serial Hb or hematocrit (Hct) measurements to accurately track the progression of bleeding and the patient's response to resuscitation [67–69].

Clinical guidelines suggest repeating these tests every 30 to 60 minutes during the initial assessment phase, as significant downward trends in Hct even during active fluid administration are highly predictive of ongoing hemorrhage [70, 71].

​Furthermore, recent advancements in non-invasive Hb monitoring have demonstrated high precision and close correlation with traditional laboratory-based results, offering a potential tool for continuous, real-time assessment in trauma settings [65].

​Predictive Value in Trauma

​Longitudinal changes in Hb and Hct levels are essential for identifying patients who require blood transfusions or urgent surgical intervention [68, 69]. These markers, when combined with other laboratory indicators such as base excess and fibrinogen levels, assist in forming a comprehensive picture of the patient's coagulation status and overall injury severity [72, 73].

Ultimately, the "stop the bleed" priority is best supported by frequent reassessment rather than a single static measurement [74].

12. Lactate and Base Deficit Monitoring

We recommend 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.
Strength of recommendation: Conditional
Level of evidence: Moderate

Rationale:

Lactate and Base Deficit as Diagnostic Tools

​For the initial assessment of patients with traumatic hemorrhage, the measurement of serum lactate and base deficit is essential. These markers serve as highly sensitive indicators for estimating the severity of blood loss and monitoring the degree of tissue hypoperfusion [75, 76].

Unlike traditional vital signs, such as systolic blood pressure, which may remain compensated in the early stages of shock, lactate and base deficit provide an objective window into cellular dysfunction and the adequacy of oxygen delivery (DO_2) [75, 76].

​Pathophysiological Rationale

​The clinical utility of these markers is rooted in cellular metabolic shifts during hemorrhagic shock. When catastrophic bleeding reduces systemic oxygen delivery, tissues are forced to transition from aerobic to anaerobic metabolism to sustain energy production. This shift results in the accumulation of lactate, a metabolic byproduct that often signals critical hypoperfusion before the onset of overt clinical hypotension [76].

​Lactate Clearance and Resuscitation Endpoints

​In the context of trauma resuscitation, the primary objective is to reverse tissue debt and restore metabolic homeostasis. Consequently, "lactate clearance" the observed reduction of lactate levels over time—is considered a superior prognostic indicator and a more definitive endpoint for resuscitation than the mere normalization of arterial blood pressure [77].

​Base Deficit and Metabolic Acidosis

​Base deficit, derived from arterial blood gas (ABG) analysis, quantifies the concentration of base required to restore the blood to a physiological pH. It is a direct reflection of metabolic acidosis in trauma patients [78, 79].

As lactate a strong acid accumulates, it releases hydrogen ions (H⁺) into circulation. These ions are neutralized by the body’s bicarbonate (HCO₃^-) buffering system; the subsequent consumption of bicarbonate stores results in an increasingly negative base deficit, signaling worsening physiological status [80].

13. Monitoring of Haemostasis

We recommend the early and repeated monitoring of haemostasis, using a traditional laboratory determination such international normalised ratio (INR), and platelet count.
Strength of recommendation: Strong
Level of evidence: Low

Rationale:

Conventional Coagulation Testing (CCT)
​Prognostic Value and Mortality Correlation

​Conventional coagulation tests (CCTs) including International Normalized Ratio (INR), Prothrombin Time (PT), activated Partial Thromboplastin Time (aPTT), platelet count, and fibrinogen concentration remain foundational in the early detection of trauma-induced coagulopathy. Because coagulopathy is a primary driver of mortality in trauma victims, the widespread availability and diagnostic reach of CCTs are critical [81].

​Research indicates that even in patients with moderate injuries, abnormal CCT results upon admission are strongly associated with increased mortality [81].

Recent evidence suggests that CCTs may offer superior predictive power for mortality compared to viscoelastic hemostatic assays (VHAs), such as Rotational Thromboelastometry (ROTEM) or Thromboelastography (TEG). Specifically, a 2025 prospective study demonstrated that prolonged INR and clotting times are more reliable prognostic indicators for survival than VHA parameters alone [82].

​Integration into Massive Transfusion Protocols (MTP)

​CCTs are essential components of massive transfusion protocols, particularly in resource-constrained environments where advanced assays may not be available. While VHAs like ROTEM may exhibit higher sensitivity in diagnosing the specific nuances of trauma-induced coagulopathy (TIC), the clinical relevance of CCTs remains undisputed; patients presenting with abnormal CCT values experience significantly higher mortality rates [83].

Consequently, these tests remain a primary guide for the targeted administration of blood products during acute resuscitation [82, 83].

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.

Strength of recommendation: Strong
Level of evidence: Moderate

Rationale:

Permissive Hypotension in Haemorrhagic Shock
​Rationale and Mechanism

​Permissive hypotension is a resuscitation strategy utilized in trauma patients with active bleeding, characterized by maintaining systolic blood pressure at sub-normal levels until definitive surgical or radiological hemorrhage control is secured. This is achieved through restricted volume replacement. The physiological objective of this approach is to prevent the "popping of the clot" the disruption of nascent hemostatic plugs which is a common complication of aggressive fluid resuscitation and high-pressure flow [84].

​Clinical Evidence and the "Lethal Triad"

​Conventional resuscitation models that prioritize the rapid restoration of normotension are frequently associated with the development of dilutional coagulopathy, hypothermia, and metabolic acidosis. These three conditions comprise the "lethal triad," which significantly drives mortality in severely injured patients [85].

Clinical evidence, most notably the landmark trial by Bickell et al., has demonstrated a distinct survival advantage in patients with penetrating truncal trauma when fluid resuscitation is limited or delayed until the point of surgical intervention [86].

​Contraindications and Implementation

​Although permissive hypotension is a cornerstone of contemporary trauma management, its application requires careful clinical judgment. This strategy is generally contraindicated in patients with concomitant traumatic brain injury (TBI), where maintaining cerebral perfusion pressure is paramount, and in scenarios involving prolonged transport times where the risk of protracted tissue ischemia may outweigh the benefits of restricted filling [84, 85].

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

We recommend maintaining mean arterial pressure ≥ 80 mmHg.
Strength of recommendation: Strong
Level of evidence: Low

Rationale:

Restrictive Fluid Resuscitation and Permissive Hypotension
​Clinical Evidence and Mortality Benefits

​The contemporary management of trauma-induced hypotension has shifted from aggressive fluid administration toward restrictive volume replacement and permissive hypotension. This paradigm was largely established by a seminal randomized controlled trial (RCT) in the 1990s, which demonstrated improved survival in patients with penetrating injuries [86].

 Recent meta-analyses of RCTs have since confirmed that in trauma patients without traumatic brain injury (TBI), restrictive fluid strategies significantly decrease mortality compared to traditional high-volume resuscitation [87, 88].

These findings are further corroborated by several meta-analyses of retrospective and mixed-methodology studies, which consistently show superior outcomes when normotension is not the immediate target [89–92].

​Complications of Aggressive Resuscitation

​Retrospective data indicate that aggressive resuscitation—often initiated in the pre-hospital setting is associated with a higher incidence of adverse outcomes. These include increased mortality, a greater necessity for damage control laparotomy, and the development of the "lethal triad" (coagulopathy, acidosis, and hypothermia). Furthermore, aggressive fluid protocols are linked to higher rates of multi-organ failure, nosocomial infections, increased transfusion requirements, and prolonged intensive care and hospital stays [93–95].

Recent evidence suggests these risks extend to pediatric populations, where higher initial crystalloid volumes are also associated with increased mortality [96].

​Contraindications and Clinical Precautions

​Despite its benefits, permissive hypotension is strictly contraindicated in patients with TBI or spinal cord injuries. In these cases, maintaining adequate mean arterial pressure is vital to ensure cerebral and spinal cord perfusion and oxygenation. The optimal balance between fluid administration and vasopressor use in these scenarios remains a subject of ongoing research, making rapid hemorrhage control the highest priority [97]. Additionally, this strategy should be applied with caution in elderly patients and those with a history of chronic arterial hypertension, as they may have a higher baseline requirement for organ perfusion.

​Summary and Future Directions

​Current literature supports a damage control resuscitation strategy that targets a reduced systolic blood pressure of 80–90 mmHg in the absence of CNS injury. However, the existing evidence base contains limitations, including small sample sizes in RCTs and potential selection bias in retrospective cohorts. While the shift toward restrictive volume replacement is clinically justified by the available data, further confirmation through adequately powered, high-quality prospective RCTs is necessary to refine these protocols.

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.
Strength of recommendation: Strong
Level of evidence: Low

Rationale:

Role of Vasopressors and Inotropes in Haemorrhagic Shock
​Noradrenaline and Early Resuscitation

​The use of noradrenaline and other vasopressors during the acute phase of trauma remains controversial. Several retrospective analyses and systematic reviews have associated vasopressor use with increased mortality or a lack of clinical benefit [98–102, 104].

One study noted that mortality was not independently linked to vasopressors unless epinephrine was administered [103]. However, these findings are often limited by significant selection bias, as patients receiving vasopressors are typically more critically ill than those who are not [104].

​Current evidence supports a strategy of restricted volume replacement and permissive hypotension (targeting a systolic blood pressure of 80–90 mmHg) without vasopressors in the initial stages of resuscitation. There is a theoretical concern that early vasopressor use may worsen organ ischemia by inducing excessive vasoconstriction. However, if these conservative measures fail and life-threatening hypotension persists (SBP < 80 mmHg), the transient use of noradrenaline is recommended to sustain tissue perfusion and prevent cardiovascular collapse.

​Arginine Vasopressin (AVP)

​Hemorrhagic shock involves a biphasic physiological response: an initial sympathoexcitatory phase followed by a sympathoinhibitory, vasodilatory phase that can severely reduce vascular tone [105]. Based on the hypothesis that profound shock leads to a deficiency in endogenous arginine vasopressin, clinical trials have investigated its supplementation.

​A well-designed randomized controlled trial (RCT) involving 100 patients demonstrated that low-dose arginine vasopressin (4 IU bolus followed by 0.04 IU/min) significantly reduced the requirement for blood product transfusions [106]. These results align with earlier data showing that adding vasopressin to resuscitation fluids decreases the total volume of fluid required over five days without increasing adverse events or 30-day mortality [107]. While promising, further high-powered research is necessary to confirm the impact of AVP on long-term morbidity and mortality.

​Managing Cardiac Dysfunction

​Cardiac dysfunction in trauma patients may result from myocardial contusion, pericardial effusion, or secondary to increased intracranial pressure from brain injury. In these instances, inotropic agents such as dobutamine or epinephrine are indicated. In the absence of advanced hemodynamic monitoring, cardiac dysfunction should be suspected if a patient remains hypotensive despite adequate fluid expansion and noradrenaline administration.

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.

Strength of recommendation: Strong
Level of evidence: Moderate

Rationale:

Crystalloid Selection and Fluid Volume
​Balanced Solutions vs. Normal Saline

​While the use of crystalloids is fundamental to a restrictive fluid strategy in trauma, the optimal type of solution remains a subject of active debate. Historically, 0.9% sodium chloride (Normal Saline) was the standard; however, its use is increasingly scrutinized due to the risk of inducing hyperchloremic acidosis and acute kidney injury (AKI), both of which may negatively impact survival [108].

​In contrast, balanced electrolyte solutions (such as Ringer’s Lactate or Plasma-Lyte) feature chloride concentrations closer to physiological levels. A large-scale RCT involving 15,802 patients suggested that balanced solutions reduce a composite outcome of death, new renal-replacement therapy, and persistent renal dysfunction [109].

However, subsequent high-quality evidence including the BaSICS trial and recent meta-analyses found no significant differences in 30-day mortality or hospital length of stay when comparing balanced solutions to saline in broader critically ill populations [110–112].

​Clinical Recommendations

​Despite the lack of a definitive survival benefit in all trials, current trauma guidelines favor balanced electrolyte solutions for initial management. If 0.9% sodium chloride is utilized, it should be restricted to a maximum volume of 1.0–1.5 L. Saline is specifically contraindicated in patients with severe metabolic acidosis, particularly when hyperchloremia is present.

​Role of Colloids and Coagulation

​The preference for crystalloids as the primary resuscitation fluid is also driven by the known inhibitory effects of synthetic colloids (such as hydroxyethyl starch and gelatin) on platelet function and the coagulation cascade.

​Research indicates that while fibrinogen concentrates can partially mitigate this dilutional and functional coagulopathy, the effect depends heavily on the type and concentration of the colloid used [113, 114]. Therefore, colloid infusions should be reserved as a secondary option for cases of excessive hemorrhage where crystalloids and vasopressors are insufficient to maintain essential tissue perfusion.

18. Avoidance of Hypotonic Solutions in TBI

We recommend that hypotonic solutions be avoided during resuscitation of patients with haemorrhagic shock in addition to Traumatic brain injury.

Strength of recommendation: Strong
Level of evidence: Moderate

Rationale:

Fluid Management in Traumatic Brain Injury (TBI)

​In patients suffering from Traumatic Brain Injury, the selection of resuscitation fluids is restricted by the need to maintain cerebral osmotic pressure. Hypotonic solutions, including Ringer’s lactate and hypotonic albumin, should be strictly avoided. The administration of these fluids can lower serum osmolality, potentially driving a fluid shift into damaged cerebral tissues and exacerbating life-threatening cerebral edema [115].

​This clinical caution is supported by secondary analysis from the PROMMTT study, which evaluated the impact of pre-hospital fluid choice. The data revealed that the use of Ringer’s lactate was associated with a higher adjusted mortality rate in the TBI population when compared to the use of isotonic normal saline [115].

19. Restriction of Colloid Use

We advise that the use of colloids to be restricted due to the adverse effects on haemostasis.
Strength of recommendation: Conditional
Level of evidence: Low

Rationale:

Adverse Effects of Colloids on Haemostasis
​Mechanisms of Coagulopathy

​The clinical rationale for restricting the use of synthetic colloids, particularly Hydroxyethyl Starches (HES) and Dextrans, is primarily based on their deleterious impact on the coagulation system [116].

These agents impair hemostasis through a dual mechanism:

1. ​Dilutional Coagulopathy: Like all large-volume intravenous fluids, they reduce the systemic concentration of platelets and essential clotting factors.
2. ​Specific Anticoagulant Effects: Colloids exert direct biochemical interference with the coagulation cascade, distinct from simple dilution [117–119].

​Direct Haemostatic Interference

​Colloid molecules directly compromise the integrity of the blood clot in several ways:

• ​Platelet Dysfunction: They interfere with both platelet adhesion and aggregation, reducing the effectiveness of the initial platelet plug.
• ​Factor Inhibition: They decrease the activity of critical coagulation components, specifically Factor VIII and Factor XIII [120].
• ​Fibrin Stability: Colloids compromise the polymerization and cross-linking of fibrin, resulting in a fragile, unstable clot that is highly susceptible to premature lysis.

​This impairment of the coagulation system is dose-dependent, meaning the risk of exacerbated hemorrhage increases significantly as larger volumes of synthetic colloids are administered [120, 121].

While albumin-induced coagulopathy is documented, it is generally considered less severe and more readily reversible with fibrinogen concentrates than the coagulopathy induced by synthetic alternatives [121].

20. Target Haemoglobin After Bleeding Control

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

Strength of recommendation: Strong
Level of evidence: Low

Rationale:

Post-Operative Haemoglobin Targets and Transfusion Strategy
​The Restrictive Transfusion Model

​Once definitive hemorrhage control is achieved, a restrictive red blood cell (RBC) transfusion strategy is recommended, targeting a hemoglobin (Hb) concentration of 7–9 g/dL. This threshold is supported by high-quality evidence indicating that a restrictive approach is non-inferior to more liberal strategies regarding patient morbidity and mortality [122].

​The landmark TRICC trial established the safety of this lower threshold for the majority of critically ill and stable patients [122].

Adopting a restrictive range is clinically advantageous as it mitigates the risks of transfusion-related complications, such as:

• ​Transfusion-Associated Circulatory Overload (TACO)
• ​Nosocomial infections
• ​Immunomodulation and suppression [123]

​By maintaining this target, clinicians utilize the body's physiological compensatory mechanisms to ensure tissue oxygenation while avoiding the adverse effects of excessive blood product administration [123, 124].

​Clinical Exceptions

​While the 7–9 g/dL target is the standard for most patients, specific populations require individualized management. Patients with acute ischemic conditions, most notably Acute Coronary Syndrome (ACS) or Traumatic Brain Injury (TBI) may necessitate a more liberal transfusion threshold to optimize cerebral and myocardial oxygen delivery and prevent secondary injury [124].

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.
Strength of recommendation: Strong
Level of evidence: Low

Rationale:

Hypothermia in Trauma Management
​Impact on Mortality and Coagulopathy

​Hypothermia is a critical independent predictor of poor outcomes in trauma, consistently correlating with increased mortality rates and a higher demand for blood products [125, 126].

A core body temperature falling below 35 °C often triggers a cascade of metabolic acidosis, hypotension, and impaired hemostasis, serving as a primary driver of trauma-induced coagulopathy [127].

​The prognostic implications of heat loss are severe; logistic regression analyses indicate that once core temperatures drop below 34 °C, the probability of mortality exceeds 80%. This elevated risk persists regardless of the patient’s injury severity score (ISS), degree of shock, or the volume of transfusions received [128].

​Hypothermia in Traumatic Brain Injury (TBI)

​In the context of severe TBI, temperature regulation is particularly vital. Both spontaneous hypothermia upon hospital admission and therapeutically induced hypothermia have been significantly linked to increased mortality rates, suggesting that maintaining normothermia is essential for neurological preservation and survival in these patients [129, 130].

​Prevention and Rewarming Strategies

​Aggressive measures to maintain normothermia should begin in the prehospital phase and continue through definitive care.

Primary strategies include:

• ​Passive Warming: Removal of wet clothing and insulation to prevent ongoing heat loss.
• ​Active Warming: Increasing the ambient temperature of the resuscitation room and utilizing forced-air warming blankets.
• ​Internal Warming: Infusion of intravenous fluids warmed to 39–40 °C and, in extreme or refractory cases, the use of extracorporeal rewarming [131].

​Furthermore, the use of specialized hypothermia management kits—originally developed for military tactical combat casualty care—is increasingly recommended for civilian use. These compact kits provide sustained dry heat for up to 10 hours and represent a practical, cost-effective adjunct for preventing the lethal progression of trauma-associated cooling [131].

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.

Strength of recommendation: Conditional
Level of evidence: Low

Rationale:

Damage Control Surgery (DCS)
​Definition and Historical Context

​In the management of severe hemorrhagic shock, the delay of definitive hemorrhage control significantly increases morbidity and mortality. To address the needs of exsanguinating patients, Damage Control Surgery (DCS) was formalized by Rotondo et al. in 1993. Originally defined for abdominal trauma, the approach prioritizes the initial control of active bleeding and contamination, followed by intraperitoneal packing and rapid temporary closure [132, 133].

​This strategy intentionally shifts the focus from definitive anatomical repair to the abbreviation of the initial operation. This allows for a period of intensive resuscitation in the ICU, where the patient's hemodynamic profile, temperature, and coagulation status can be stabilized prior to returning to the operating room for final management [133].

​Benefits and Clinical Risks

​The primary advantage of DCS is the stabilization of the "lethal triad," providing clinicians with the necessary time to reverse physiological insults before complex reconstructive surgery is attempted [134].

However, DCS carries a high risk of post-operative complications, including:

• ​Surgical site infections and sepsis.
• ​Incisional hernias and wound dehiscence.
• ​Abdominal compartment syndrome.
• ​The inherent physiological burden of multiple subsequent surgical procedures [134].

​Reducing the Need for Damage Control

​While DCS remains a life-saving intervention, recent shifts in Damage Control Resuscitation (DCR) including the early correction of coagulopathy, rapid hemorrhage control, and the avoidance of excessive crystalloid administration have been shown to improve physiological stability earlier in the treatment timeline. These adjunctive strategies may potentially reduce the necessity for full damage control procedures in a subset of severely injured patients [135].

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.
Strength of recommendation: Strong
Level of evidence: Low

Rationale:

Emergency Pelvic Stabilization
​Role of External Stabilization

​For patients presenting with unstable pelvic ring fractures, emergency external stabilization is a critical component of initial hemorrhage control. These techniques are widely utilized because they reduce pelvic volume and provide mechanical stability, which facilitates the tamponade of venous bleeding and protects nascent clots from disruption [136].

​Clinical Application and DCO Principles

​The use of non-invasive pelvic binders has become a standard of care in the pre-hospital and early clinical phases of resuscitation. However, the decision to apply such a device must be tailored to the patient's specific injury morphology. In alignment with the principles of Damage Control Orthopaedics (DCO), the primary objective is to prioritize rapid physiological stabilization and hemorrhage control over definitive anatomical fixation [137–139].

​Data from major registries indicate that while binders are highly effective for "open-book" (anteroposterior compression) patterns, their appropriateness depends on a careful assessment of the fracture pattern to ensure that the compression does not exacerbate certain types of lateral compression injuries [137].

24. Topical Haemostatic Agents

We consider the use of topical haemostatic agents with packing for venous or moderate arterial bleeding associated with parenchymal injuries.

Strength of recommendation: Conditional
Level of evidence: Moderate

Rationale:

Local Haemostatic Agents
​Role as Surgical Adjuncts

​A diverse array of local hemostatic agents is currently available to supplement traditional surgical methods, such as suturing or cauterization. These topical adjuncts are particularly advantageous in scenarios where anatomical access is restricted or when dealing with diffuse, non-compressible bleeding from parenchymal organs, bone, or vascular anastomoses [140, 142].

​Clinical Evidence and Survival

​The efficacy of these agents is well-documented in high-acuity settings. A retrospective review of the UK Joint Trauma Registry demonstrated that the early application of hemostatic dressings in severely injured military casualties was significantly associated with increased survival rates [140].

Similarly, in the prehospital setting, a systematic review corroborated the value of these dressings in managing catastrophic external hemorrhage before definitive surgical intervention could be reached [148].

​Specialized Applications

​Extensive clinical experience in humans has validated the use of various formulations across multiple surgical disciplines:

• ​Gelatine-Thrombin Matrices: Highly effective in vascular, renal, and spinal surgeries for managing active oozing [141, 145, 146].
• ​Fibrin Sealants: Proven to improve haemostasis in peripheral vascular procedures [142].
• ​Oxidized Cellulose and Collagen-Based Composites: Utilized effectively in thoracic surgery and for controlling bone-surface bleeding at donor sites [143, 144, 147].
• ​Intra-abdominal Packing: The combination of traditional laparotomy pads with haemostatic gauze (e.g., QuikClot) during damage control laparotomy has been analysed for safety and efficacy in stabilizing patients with profound intra-abdominal haemorrhage [149].

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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 hours.
Strength of recommendation: Strong
Level of evidence: High

Rationale:

Tranexamic Acid (TXA) in Trauma Resuscitation
​Clinical Efficacy and Mortality Benefit

​Tranexamic acid (TXA) has established itself as a cornerstone in the management of trauma patients at risk of significant hemorrhage. Large-scale clinical trials have demonstrated that its administration can reduce overall mortality by 1.5% and, more significantly, decrease deaths specifically attributed to bleeding by approximately one-third [150, 151]. Its mechanism as an antifibrinolytic helps stabilize formed clots, preventing their premature breakdown during the hyperfibrinolytic state often seen in trauma-induced coagulopathy.

​Pre-hospital Administration and Dosing Strategies

​The transition of TXA administration to the pre-hospital setting has been a major focus of recent research. In a randomized controlled trial of 927 trauma patients, a 1 g pre-hospital dose of TXA administered within two hours of injury resulted in a 30-day mortality rate of 8.1%, compared to 9.9% in the placebo group [155].

​The impact of subsequent in-hospital dosing appears to follow a dose-response relationship. Data indicates that following a pre-hospital dose, 30-day mortality rates were lowest (7.3%) in patients who received a follow-up 1 g bolus plus a 1 g infusion, compared to those receiving an infusion only (7.8%) or no additional in-hospital TXA (9.3%) [155].

​The "Golden Hour" and Patient Selection

​The survival benefit of TXA is highly time dependent. Secondary analysis confirms that patients treated within one hour of injury particularly those with a shock index < 0.9 experienced a 65% lower likelihood of 30-day mortality [155].

Furthermore, early administration is associated with a lower incidence of multiorgan failure and reduced 24-hour transfusion requirements. Conversely, delayed treatment (> 3 hours from injury) has been shown in related literature to potentially increase the risk of death, reinforcing the necessity of early intervention [150, 155].

​Recent applications have also expanded into Traumatic Brain Injury (TBI), where TXA has been shown to reduce the progression of intracranial hemorrhagic masses and improve survival in cases of mild-to-moderate TBI, provided it is administered promptly [151–154].

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.
Strength of recommendation: Strong
Level of evidence: Low

Rationale:

Initial Transfusion Strategies: Fixed-Ratio Protocols
​Empirical Ratio-Driven Resuscitation

​During the critical interval between hospital arrival and the availability of laboratory coagulation results, many trauma centers employ an empirical, ratio-driven transfusion strategy. This approach involves the administration of Fresh Frozen Plasma (FFP), platelets, and packed Red Blood Cells (pRBCs) in fixed ratios to pre-emptively manage trauma-induced coagulopathy. While the precise benefit of fixed ratios remains a subject of debate, this strategy aims to mimic the composition of whole blood and prevent the dilution of clotting factors [157].

​The PROPPR Trial and Haemostatic Outcomes

​The definitive evidence for ratio-driven resuscitation comes from the PROPPR trial, which randomized 680 severely injured patients to receive blood products in either a 1:1:1 ratio (where platelets are included in the first transfusion pack) or a 1:1:2 ratio (where platelets are delayed until the second pack) [156].

​The study found that while overall 24-hour and 30-day mortality rates were comparable between the two groups.

The 1:1:1 ratio offered significant physiological advantages:

• ​Improved Haemostasis: Patients in the 1:1:1 group achieved formal haemostasis significantly faster than those in the 1:1:2 group.
• ​Reduced Exsanguination: There was a notable reduction in deaths specifically attributed to early exsanguination in the 1:1:1 cohort [156].

​Consequently, fixed-ratio protocols, particularly the 1:1:1 approach are widely integrated into Massive Transfusion Protocols (MTPs) to stabilize patients during the hyperacute phase of bleeding until goal-directed therapy can be initiated [157].

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.
Strength of recommendation: Strong
Level of evidence: Low

Rationale:

Calcium Homeostasis in Major Haemorrhage

​In the management of patients with major trauma, maintaining normocalcaemia is a critical yet often overlooked component of resuscitation. It is strongly advised to perform frequent monitoring of ionized calcium levels, particularly during the activation of massive transfusion protocols. 

Impact of Transfusion on Calcium Levels

​The primary driver of hypocalcemia during resuscitation is the administration of large volumes of blood products. These products contain citrate, an anticoagulant that binds to free ionized calcium, rapidly lowering its systemic concentration. Since ionized calcium is a vital cofactor (Factor IV) in the coagulation cascade essential for the conversion of prothrombin to thrombin and the stabilization of fibrin low levels can severely exacerbate trauma-induced coagulopathy [158]. 

​Clinical Intervention

​Clinicians should maintain ionized calcium within normal physiological limits to support both hemostasis and myocardial contractility. Calcium supplementation (typically via calcium chloride or calcium gluconate) must be administered promptly whenever hypocalcemia is identified or empirically during rapid transfusion to prevent the "citrate toxicity" effect [158].

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 intravenous phytomenadione (vitamin K1) in addition to FFP".
Strength of recommendation: Strong
Level of evidence: High

Rationale:

Reversal of Vitamin K Antagonist (VKA) Therapy
​Multi-Modal Reversal Strategy

​In trauma patients presenting significant hemorrhage while on Vitamin K Antagonist (VKA) therapy (e.g., Warfarin), emergency reversal of anticoagulation is a critical priority. Current guidelines recommend a dual-action approach: the immediate administration of four-factor Prothrombin Complex Concentrate (PCC) supplemented with 5–10 mg of intravenous phytomenadione (Vitamin K1) [159, 160].

​Physiological Rationale

​The necessity for this combined therapy is rooted in the distinct pharmacokinetics of the reversal agents:

• ​Intravenous Vitamin K: Provides the essential substrate for the hepatic synthesis of functional Factors II, VII, IX, and X. While vital for sustained hemostasis, the onset of action is delayed, typically requiring 6 to 12 hours for the liver to produce sufficient new clotting factors [161].
• ​Prothrombin Complex Concentrate (PCC): Offers a concentrated source of the Vitamin K-dependent factors, bypassing the need for hepatic synthesis and providing immediate correction of the International Normalized Ratio (INR).

​PCC vs. Fresh Frozen Plasma (FFP)

​Historically, Fresh Frozen Plasma (FFP) was utilized for VKA reversal; however, its use in trauma is increasingly restricted by volume limitations. Achieving effective reversal with FFP often necessitates dosages of 15–30 mL/kg, which equates to 1 to 2 liters of fluid for an average adult. This high-volume requirement carries significant risks, including Transfusion-Associated Circulatory Overload (TACO) and acute cardiac strain [161].

​Furthermore, high-quality randomized evidence, such as the INCH trial, has demonstrated that PCC is superior to FFP in achieving rapid normalization of the INR and limiting the expansion of life-threatening bleeding, particularly in cases of intracranial hemorrhage [161].