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.