BACKGROUND: Severe trauma continues to represent a global public health issue and mortality and morbidity in trauma patients remains substantial. A number of initiatives have aimed to provide guidance on the management of trauma patients. This document focuses on the management of major bleeding and coagulopathy following trauma and encourages adaptation of the guiding principles to each local situation and implementation within each institution. METHODS: The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma was founded in 2004 and included representatives of six relevant European professional societies. The group used 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 reconsidered and revised based on new scientific evidence 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. This guideline represents the fourth edition of a document first published in 2007 and updated in 2010 and 2013. RESULTS: The guideline now recommends that patients be transferred directly to an appropriate trauma treatment centre and encourages use of a restricted volume replacement strategy during initial resuscitation. Best-practice use of blood products during further resuscitation continues to evolve and should be guided by a goal-directed strategy. The identification and management of patients pre-treated with anticoagulant agents continues to pose a real challenge, despite accumulating experience and awareness. The present guideline should be viewed as an educational aid to improve and standardise the care of the bleeding trauma patients across Europe and beyond. This document may also serve as a basis for local implementation. Furthermore, local quality and safety management systems need to be established to specifically assess key measures of bleeding control and outcome. CONCLUSIONS: A multidisciplinary approach and adherence to evidence-based guidance are key to improving patient outcomes. The implementation of locally adapted treatment algorithms should strive to achieve measureable improvements in patient outcome.

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

Department of Anaesthesia Pain Management and Perioperative Medicine Dalhousie University Halifax QE 2 Health Sciences Centre 10 West Victoria 1276 South Park St Halifax NS B3H 2Y9 Canada

Department of Anaesthesiology and Intensive Care Charles University Prague Faculty of Medicine in Hradec Kralove Sokolska 581 50005 Hradec Kralove Czech Republic

Department of Anaesthesiology Perioperative Medicine and Intensive Care J E Purkinje University Masaryk Hospital Usti nad Labem Socialni pece 3316 12A 40113 Usti nad Labem Czech Republic

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

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

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

Department of Research and Development Charles University Prague Faculty of Medicine in Hradec Kralove Sokolska 581 50005 Hradec Kralove Czech Republic

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

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

Department of Traumatology General and Teaching Hospital Celje Oblakova 5 3000 Celje Slovenia

Division of Anaesthesia Intensive Care and Emergency Medicine Brest University Hospital Boulevard Tanguy Prigent 29200 Brest France

Emergency Medicine Academic Group University of Leicester University Road Leicester LE1 7RH UK

Faculty of Health School of Medicine Witten Herdecke University Ostmerheimer Strasse 200 Building 38 51109 Cologne Germany

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

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

Ludwig Boltzmann Institute for Experimental and Clinical Traumatology Lorenz Boehler Trauma Centre Donaueschingenstrasse 13 1200 Vienna Austria

Servicio de Medicina Intensiva Complejo Hospitalario Universitario de Granada ctra de Jaén s n 18013 Granada Spain

Shock and Trauma Centre S Camillo Hospital Viale Gianicolense 87 00152 Rome Italy

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