BACKGROUND: Severe traumatic injury continues to present challenges to healthcare systems around the world, and post-traumatic bleeding remains a leading cause of potentially preventable death among injured patients. Now in its fifth edition, this document aims to provide guidance on the management of major bleeding and coagulopathy following traumatic injury and encourages adaptation of the guiding principles described here to individual institutional circumstances and resources. METHODS: The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma was founded in 2004, and the current author group included representatives of six relevant European professional societies. The group applied a structured, evidence-based consensus approach to address scientific queries that served as the basis for each recommendation and supporting rationale. Expert opinion and current clinical practice were also considered, particularly in areas in which randomised clinical trials have not or cannot be performed. Existing recommendations were re-examined and revised based on scientific evidence that has emerged since the previous edition and observed shifts in clinical practice. New recommendations were formulated to reflect current clinical concerns and areas in which new research data have been generated. RESULTS: Advances in our understanding of the pathophysiology of post-traumatic coagulopathy have supported improved management strategies, including evidence that early, individualised goal-directed treatment improves the outcome of severely injured patients. The overall organisation of the current guideline has been designed to reflect the clinical decision-making process along the patient pathway in an approximate temporal sequence. Recommendations are grouped behind the rationale for key decision points, which are patient- or problem-oriented rather than related to specific treatment modalities. While these recommendations provide guidance for the diagnosis and treatment of major bleeding and coagulopathy, emerging evidence supports the author group's belief that the greatest outcome improvement can be achieved through education and the establishment of and adherence to local clinical management algorithms. CONCLUSIONS: A multidisciplinary approach and adherence to evidence-based guidance are key to improving patient outcomes. If incorporated into local practice, these clinical practice guidelines have the potential to ensure a uniform standard of care across Europe and beyond and better outcomes for the severely bleeding trauma patient.

Department of Anaesthesia and ICU AUSL della Romagna Infermi Hospital Rimini Viale Settembrini 2 1 47924 Rimini Italy

Department of Anaesthesia and Intensive Care Hôpitaux Universitaires Paris Sud University of Paris XI Faculté de Médecine Paris Sud 78 rue du Général Leclerc F 94275 Le Kremlin Bicêtre Cedex France

Department of Anaesthesiology Perioperative Medicine and Intensive Care J E Purkinje University Masaryk Hospital Usti nad Labem Socialni pece 3316 12A CZ 40113 Usti nad Labem Czech Republic Centre for Research and Development University Hospital Hradec Kralove Hradec Kralove Czech Republic Sokolska 581 CZ 50005 Hradec Kralove Czech Republic Department of Anaesthesiology and Intensive Care Medicine Faculty of Medicine in Hradec Kralove Charles University Simkova 870 CZ 50003 Hradec Kralove Czech Republic Department of Anaesthesia Pain Management and Perioperative Medicine QE 2 Health Sciences Centre Dalhousie University Halifax 10 West Victoria 1276 South Park St Halifax NS B3H 2Y9 Canada

Department of Anaesthesiology University Hospital Aachen RWTH Aachen University Pauwelsstrasse 30 D 52074 Aachen Germany

Department of Cardiac Anaesthesia and Intensive Care C C Iliescu Emergency Institute of Cardiovascular Diseases Sos Fundeni 256 258 RO 022328 Bucharest Romania

Department of Intensive Care Erasme University Hospital Université Libre de Bruxelles Route de Lennik 808 B 1070 Brussels Belgium

Department of Surgery and Trauma Karolinska University Hospital S 171 76 Solna Sweden

Department of Trauma and Orthopaedic Surgery Cologne Merheim Medical Centre University of Witten Herdecke Ostmerheimer Strasse 200 D 51109 Cologne Germany

Department of Traumatology General and Teaching Hospital Celje Medical Faculty Ljubljana University SI 3000 Celje Slovenia

Hotel Dieu University Hospital 1 place du Parvis de Notre Dame F 75181 Paris Cedex 04 France

Institute of Anaesthesiology University of Zurich and University Hospital Zurich Raemistrasse 100 CH 8091 Zurich Switzerland

King's College and Departments of Haematology and Pathology Guy's and St Thomas' NHS Foundation Trust Westminster Bridge Road London SE1 7EH UK

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