After my recent, hugely enjoyable, trip to Austria and attendance at the “notfallmedizin 2016” where, as well as doing a talk about FOAMed, I chaired a session on “Volume and Coagulation” I became aware that the view of our colleagues in mainland Europe about some aspects of resuscitation of traumatically injured patients may differ from ours in the UK. Reference was made there to the “European Guideline on management of major bleeding and coagulopathy follow trauma: 4th Edition” by some speakers and this was published a few days ago.
Spanning 55 pages and with 677 references this a comprehensive document that makes 39 recommendations, each of which are graded from 1A (Strong recommendation) across six categories to 2C (Weak recommendation).
Before going any further it is worth noting who the panel were who drew up these guidelines and their methods for doing so. This iteration of guideline has been formulated over about 18 months of remote telephone or internet based meetings, “extensive electronic communication” and one face to face conference in April 2015 where the wording of each recommendation was finalised. The group of 19 members included representatives from, and was endorsed by, several European societies including the European Society for Emergency Medicine and one of the authors was the UK’s very own Tim Coats, Professor of EM in Leicester and lead author on CRASH-2.
Many of the recommendations are not controversial: time between injury and bleeding control should be minimised (1B); use of tourniquets to stop life threatening bleeding (1B); avoidance of hypoxaemia (1A) for example, but the recommendation for choice of resuscitation fluid will come as a surprise to many UK readers.
Recommendation 16 We recommend that fluid therapy using isotonic crystalloid solutions be initiated in the hypotensive bleeding patient (Grade 1A – Strong recommendation/High quality evidence). This is in direct opposition to the guidance issued by NICE only a few months ago where recommendation 1.5.22 states “in pre-hospital settings only use crystalloids to replace fluid volume in patients with active bleeding if blood components are not available” and 1.5.23 goes on to say “in hospital settings do not use crystalloids for patients with active bleeding”.
Speaking to delegates in Austria it seemed that there is a real difference of opinion between “mainland Europe” and the UK, US and Australasia about which approach is correct. The explanatory paragraph in the European guideline doesn’t even talk about the use of blood products, but rather discusses the relative merits of which crystalloid should be used and whether colloids are an option – something that Karim Brohi (one of the UK’s leading voices on trauma management) would seemingly definitely not endorse….
To be fair the European guideline does go on, in a section called “initial coagulation resuscitation” to recommend “In the initial management of patients with expected massive haemorrhage we recommend one of two strategies: plasma (FFP or pathogen inactivated plasma) in a plasma-RBC ratio of 1:2 as needed (1B) or Fibrinogen concentrate and RBC according to Hb level (1C)”, but this seems to be mainly concerned with the correction of clotting abnormalities rather than volume resuscitation.
The other recommendation, related again to volume and BP management, that may not sit easily is number 15: “in the presence of life-threatening hypotension we recommend administration of vasopressors in addition to fluids to maintain target arterial pressure.” These agents are not mentioned at all in the NICE guidance and as a Trauma Team Leader I have definitely been directing my management of the hypotensive, bleeding patient towards volume replacement rather than vasopressor use.
A significant portion of the European guideline is focussed on the correction of coagulation disorders and it makes some excellent recommendations about targeting therapies to maintain clotting. Many of these aspects often fall outside the remit of the Emergency Physician, as these patients are often on their way to theatre before initial blood test results are known, but I am sure that as we move point of care testing into the resus room correction of coagulopathy will become more of a focus for trauma team leaders.
So where does this leave us? Many of the aspects of trauma management seem universally agreed, but there is still work to be done to achieve a worldwide consensus in some areas. I am hoping that this guideline (and blog post) will prompt further discussion about what we should be using for volume resuscitation both prehospitally and in hospital. I had very fixed ideas about what was “right” but after my trip to Austria and meeting some clearly very clever and knowledgable physicians and reading this guideline it has given me pause for thought. I’ll be sticking with my “give blood and plasma” approach for now, but I wouldn’t be surprised if in a few years what we in the UK have recently become wedded to isn’t as straightforward as we first thought.
I’d encourage you all to read the European guideline and look forward to hearing your views in the comments section below and on Twitter.
5 thoughts on “The European Guideline on Management of Major Bleeding – are you in or out?”
Thanks Iain – good piece. I agree: no good grounds to change. The niceties of precise ratios really don’t matter. The approach I try to follow: if they’re bleeding give them PRBCs and FFP (aiming for 1:1…..recognising you’ll be lucky) BUT main focus must remain stopping the bleeding ASAP.
On the subject of ROTEM / TEG I don’t think we should even be thinking about this in the ED – it’ll simply introduce delays in getting on with definitive management in the appropriate place (theatre / IR or ICU)
As for vasopressors: they’ve got a place in patients with significant TBI but the WHOLE TEAM needs to know they are being used. I get a bit frustrated by the anaesthetist with a covert syringe of metaraminol!
Thanks again for taking the trouble to post.
You are right about cultural differences – there are also differences in the availability of blood products and drugs around European, so writing a guideline for everyone is interesting. The intention was to encompass a range of practice where the evidence is weak – so maybe less didactic and a bit more “fuzzy” than NICE (I like fuzzy guidelines rather than false certainty, but this is maybe another debate). Practice and systems, especially Austria / Germany / Switzerland, is different from the UK – interestingly the trauma outcomes seem much the same. In addition, as Emergency Medicine does not really exist in much of Europe it is intensivists who lead resuscitation, which I think brings a different perspective.
Saline is in a the first fluid for the practical reason that if early fluid is needed, nobody (OK, very few) has blood, plasma and platelets immediately available (especially prehospital). The intention was to advise a switch to blood products as soon as available – maybe the wording has failed to convey this. Advising “only blood” approach risks significant delay in treatment – especially when writing a guideline for all situations, not just the high performance trauma unit. There is a danger that ‘give only blood’ = ‘give nothing for a long time’. Given the risks the evidence for “blood only” was not considered strong enough to mandate the approach – but we did not want to make a blood products only resuscitation ‘wrong’. A range of practice is ‘right’ on the basis of the current evidence (so this Guideline fuzzier than NICE).
The recommendation for Adrenaline is in the context that fluid resuscitation is ongoing – so I don’t think that you are right in interpreting this as an alternative. The wording is “life threatening hypotension” and “vasopressors in addition to fluid” – in other words if the fluids are insufficient and the patient is going down the pan add in a vasopressor – while on the way to definitive intervention.
There are advocates of colloid fluid around Europe, so this needed to be reflected by keeping the crystallised / colloid debate in the Guideline, It is probably has less relevance to the UK as practice here has already changed away from colloids.
I really like ‘fuzzy guidelines’ which leave open a range of practice where evidence is weak – you really don’t need to force certainty and create an algorithm.
Thank you so much for taking the time to reply. This really does illustrate the power of FOAMed for informed and educational discussion.
Regarding vsasopressors – I have almost seen their use in the past as a “failure” to adequately volume resuscitate and even now would be reluctant to use them at all. This guideline definitely gave me food for thought.
The other striking thing for me, not just from this guideline, but talking to delegates at the conference in Austria, was just how much the practice of EM differs across Europe. There are definitely things we could all learn from each other to advance patient care.
But even the Germans are moving away from crystalloids:
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