The STOP the Bleeding Campaign

  • Rolf Rossaint1Email author,

    Affiliated with

    • Bertil Bouillon2,

      Affiliated with

      • Vladimir Cerny3, 4,

        Affiliated with

        • Timothy J Coats5,

          Affiliated with

          • Jacques Duranteau6,

            Affiliated with

            • Enrique Fernández-Mondéjar7,

              Affiliated with

              • Daniela Filipescu8,

                Affiliated with

                • Beverley J Hunt9,

                  Affiliated with

                  • Radko Komadina10,

                    Affiliated with

                    • Marc Maegele11,

                      Affiliated with

                      • Giuseppe Nardi12,

                        Affiliated with

                        • Edmund Neugebauer13,

                          Affiliated with

                          • Yves Ozier14,

                            Affiliated with

                            • Louis Riddez15,

                              Affiliated with

                              • Arthur Schultz16,

                                Affiliated with

                                • Jean-Louis Vincent17,

                                  Affiliated with

                                  • Donat R Spahn18 and

                                    Affiliated with

                                    • the STOP the Bleeding Campaign

                                      Affiliated with

                                      Critical Care201317:136

                                      DOI: 10.1186/cc12579

                                      Published: 26 April 2013

                                      Abstract

                                      According to the World Health Organization, traumatic injuries worldwide are responsible for over 5 million deaths annually. Post-traumatic bleeding caused by traumatic injury-associated coagulopathy is the leading cause of potentially preventable death among trauma patients. Despite these facts, awareness of this problem is insufficient and treatment options are often unclear. The STOP the Bleeding Campaign therefore aims to increase awareness of the phenomenon of post-traumatic coagulopathy and its appropriate management by publishing European guidelines for the management of the bleeding trauma patient, by promoting and monitoring the implementation of these guidelines and by preparing promotional and educational material, organising activities and developing health quality management tools. The campaign aims to reduce the number of patients who die within 24 hours after arrival in the hospital due to exsanguination by a minimum of 20% within the next 5 years.

                                      Introduction

                                      Injuries worldwide cause more than 16,000 deaths per day [1]. Bleeding is a leading cause of death following traumatic injury for those patients who are admitted to hospital, and trauma-associated coagulopathy increases both the risk and severity of bleeding. At least 20% of severely injured patients (Injury Severity Score ≥16) are already coagulopathic upon arrival in the emergency room [24], but awareness of this problem is low, leading to late recognition and delayed treatment of coagulopathy. This lack of awareness may cause harm to our patients, because the coagulopathy associated with traumatic injury contributes significantly to secondary injury and results in a several-fold increase in morbidity and mortality [5, 6]. Moreover, diagnostic and treatment options are often unclear and not well investigated.

                                      Inspired by the success of two other medical awareness campaigns - the Anti-Obesity Campaign created in 1999 [7] and the Surviving Sepsis Campaign launched in 2002 [8] - a multidisciplinary, pan-European group of experts with specialties in surgery, anaesthesia, emergency medicine, intensive care medicine and haematology are now in the process of launching a campaign to counteract preventable deaths from uncontrolled bleeding following traumatic injury. This task force, including representatives of relevant European professional societies - the European Society of Anaesthesiology, the European Society of Intensive Care Medicine, the European Shock Society, the European Society of Trauma and Emergency Surgery and the European Society for Emergency Medicine - published a review article [9] and developed guidelines for the management of the bleeding trauma patient, which have been updated at 3-year intervals [1012]. The group believes that an active campaign to improve awareness of traumatic coagulopathy will help to ensure that guideline recommendations are universally implemented.

                                      Aim and acronym of the STOP the Bleeding Campaign

                                      The STOP the Bleeding Campaign aims to reduce morbidity and mortality from bleeding following traumatic injury by implementing a programme to support haemostatic resuscitation that includes clinical practice guidelines, patient management bundles, educational tools and adherence control measures to ensure the early recognition and treatment of bleeding and traumatic coagulopathy. The goal of the campaign is to reduce the number of patients who die within 24 hours after arrival in hospital due to exsanguination by a minimum of 20% within 5 years.

                                      The acronym STOP comprises the following elements: Search for patients at risk of coagulopathic bleeding; Treat bleeding and coagulopathy as soon as they develop; Observe the response to interventions; Prevent secondary bleeding and coagulopathy.

                                      Search for patients at risk of coagulopathic bleeding

                                      The early recognition of bleeding and coagulopathy requires awareness of the phenomenon. Although the Advanced Trauma Life Support programme addresses the circulatory problem during the primary survey and suggests that bleeding sources should be sought if shock is present [13], the issue of coagulopathy associated with traumatic injury is not well addressed at present. The STOP concept specifically addresses three important aspects of coagulopathic bleeding: rapid detection of all relevant bleeding sources; estimation of blood loss, risk of ongoing haemorrhage and need for massive transfusion; and targeted screening for and monitoring of coagulopathy upon arrival in hospital and intermittently thereafter.

                                      Treat bleeding and coagulopathy as soon as they develop

                                      Bleeding should be stopped using surgical or other means as quickly as possible. Damage control surgery should be applied to patients in shock, including packing of the abdomen in haemorrhagic patients, application of external fixators to long bone fractures and an attempt to limit operation times to ≤90 minutes per intervention. Aggressive treatment of coagulopathy should be implemented simultaneously, including the early administration of tranexamic acid and the use of blood products according to evidence-based clinical practice guidelines.

                                      Observe the response to interventions

                                      After treatment, the response to intervention should be observed. Important variables to be considered include the surgeon's interoperative judgement, laboratory tests, thrombelastometric assessment and the necessity of continued blood product administration. The vital status - especially blood pressure, pulse rate, lactate and urinary output - should also be evaluated.

                                      Prevent secondary bleeding and coagulopathy

                                      Especially important is the avoidance of secondary coagulopathy. Measures may include the use of damage control surgery rather than primary definitive surgery in patients in shock and the prevention of all risk factors that trigger haemostatic disorders, including hypothermia and acidosis.

                                      Main action points for implementation

                                      To achieve these goals, several important action points must be undertaken in parallel. The campaign must be visible not only for researchers but also for clinicians involved in the treatment of bleeding trauma patients. Although published national and international guidelines that reflect the current evidence and a scientific evaluation of state-of-the-art diagnostic and treatment options and that identify areas which require further research are helpful to guide the clinician in the treatment of the bleeding trauma patient, the translation into clinical practice represents a challenge for busy clinicians, particularly in an emergency setting. The campaign therefore aims to develop and test diagnostic and interventional patient management bundles to aid in the learning and implementation process, as demonstrated during the Surviving Sepsis Campaign [14].

                                      Evidence from the Surviving Sepsis Campaign has also shown that the adherence to the management bundles must be monitored and - more importantly - is associated with an increase in survival [15]. We therefore aim to create a technical tool that can be used to monitor and document institutional adherence to patient management principles in national or international databases. If possible, these databases should be aligned to permit comparative effectiveness research.

                                      In addition, awareness and implementation of the principles represented by the STOP the Bleeding Campaign should be supported by educational programmes, and adaptation of the guiding principles to the local situation in each institution and the effectiveness of the programme should be evaluated using validated tools on a periodic basis.

                                      Support and funding

                                      The experts initiating the STOP the Bleeding Campaign request the support of European professional societies, political bodies, national and international health and funding organisations as well as pharmaceutical and device manufacturers. If these diverse groups recognise and accept the challenge presented by the bleeding trauma patient and enable a global campaign to induce clinicians involved in the treatment of the trauma patient to embrace evidence-based management principles, it will be possible to decrease mortality due to exsanguination in the coming years.

                                      Abbreviations

                                      STOP: 

                                      Search for patients at risk of coagulopathic bleeding: Treat bleeding and coagulopathy as soon as they develop: Observe the response to interventions: Prevent secondary bleeding and coagulopathy.

                                      Declarations

                                      Acknowledgements

                                      Support and manuscript preparation was provided by Physicians World Europe GmbH (Mannheim, Germany) supported by an unrestricted grant from CSL Behring GmbH (Marburg, Germany).

                                      Authors’ Affiliations

                                      (1)
                                      Department of Anaesthesiology, University Hospital Aachen, RWTH Aachen University
                                      (2)
                                      Department of Trauma and Orthopaedic Surgery, University of Witten/Herdecke, Cologne-Merheim Medical Centre
                                      (3)
                                      Faculty of Medicine in Hradec Králové, Department of Anaesthesiology and Intensive Care Medicine, University Hospital Hradec Králové
                                      (4)
                                      Department of Anesthesia, Pain Management and Perioperative Medicine, Dalhousie University
                                      (5)
                                      Accident and Emergency Department, University of Leicester
                                      (6)
                                      Department of Anaesthesia and Intensive Care, University of Paris XI, Faculté de Médecine Paris-Sud
                                      (7)
                                      Department of Emergency and Critical Care Medicine, University Hospital Virgen de las Nieves
                                      (8)
                                      Department of Cardiac Anaesthesia and Intensive Care, C. C. Iliescu Emergency Institute of Cardiovascular Diseases
                                      (9)
                                      Guy’s & St Thomas’ Foundation Trust
                                      (10)
                                      Department of Traumatology, General and Teaching Hospital Celje
                                      (11)
                                      Department of Trauma and Orthopaedic Surgery, University of Witten/Herdecke, Cologne-Merheim Medical Centre
                                      (12)
                                      Shock and Trauma Centre, S. Camillo Hospital
                                      (13)
                                      Institute for Research in Operative Medicine (IFOM), Witten/Herdecke University
                                      (14)
                                      Division of Anaesthesia, Intensive Care and Emergency Medicine, Brest University Hospital, Boulevard Tanguy Prigent
                                      (15)
                                      Department of Surgery and Trauma, Karolinska University Hospital
                                      (16)
                                      Ludwig-Boltzmann-Institute for Experimental and Clinical Traumatology, Lorenz Boehler Trauma Centre
                                      (17)
                                      Jean-Louis Vincent, Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles
                                      (18)
                                      Institute of Anaesthesiology, University Hospital Zurich

                                      References

                                      1. World Health Organization: Violence, Injuries, and Disability: Biennial 2006–2007 Report. Geneva: World Health Organization; 2008.
                                      2. Frith D, Goslings JC, Gaarder C, Maegele M, Cohen MJ, Allard S, Johansson PI, Stanworth S, Thiemermann C, Brohi K: Definition and drivers of acute traumatic coagulopathy: clinical and experimental investigations. J Thromb Haemost 2010, 8:1919–1925.PubMedView Article
                                      3. Maegele M, Lefering R, Yucel N, Tjardes T, Rixen D, Paffrath T, Simanski C, Neugebauer E, Bouillon B: Early coagulopathy in multiple injury: an analysis from the German Trauma Registry on 8724 patients. Injury 2007, 38:298–304.PubMedView Article
                                      4. Brohi K, Singh J, Heron M, Coats T: Acute traumatic coagulopathy. J Trauma 2003, 54:1127–1130.PubMedView Article
                                      5. MacLeod JB, Lynn M, McKenney MG, Cohn SM, Murtha M: Early coagulopathy predicts mortality in trauma. J Trauma 2003, 55:39–44.PubMedView Article
                                      6. Moore EE, Knudson MM, Jurkovich GJ, Fildes JJ, Meredith JW: Emergency traumatologist or trauma and acute care surgeon: decision time. J Am Coll Surg 2009, 209:394–395.PubMedView Article
                                      7. Carraro R, Garcia Cebrian M: Role of prevention in the contention of the obesity epidemic. Eur J Clin Nutr 2003,57(Suppl 1):S94-S96.PubMedView Article
                                      8. Slade E, Tamber PS, Vincent JL: The Surviving Sepsis Campaign: raising awareness to reduce mortality. Crit Care 2003, 7:1–2.PubMedView Article
                                      9. Rossaint R, Cerny V, Coats TJ, Duranteau J, Fernández-Mondéjar E, Gordini G, Stahel PF, Hunt BJ, Neugebauer E, Spahn DR: Key issues in advanced bleeding care in trauma. Shock 2006, 26:322–331.PubMedView Article
                                      10. Spahn DR, Cerny V, Coats TJ, Duranteau J, Fernandez-Mondejar E, Gordini G, Stahel PF, Hunt BJ, Komadina R, Neugebauer E, Ozier Y, Riddez L, Schultz A, Vincent JL, Rossaint R, Task Force for Advanced Bleeding Care in Trauma: Management of bleeding following major trauma: a European guideline. Crit Care 2007, 11:R17.PubMedView Article
                                      11. Rossaint R, Bouillon B, Cerny V, Coats TJ, Duranteau J, Fernandez-Mondejar E, Hunt BJ, Komadina R, Nardi G, Neugebauer E, Ozier Y, Riddez L, Schultz A, Stahel PF, Vincent JL, Spahn DR, Task Force for Advanced Bleeding Care in Trauma: Management of bleeding following major trauma: an updated European guideline. Crit Care 2010, 14:R52.PubMedView Article
                                      12. Spahn DR, Bouillon B, Cerny V, Coats TJ, Duranteau J, Fernández-Mondéjar E, Filipescu D, Hunt BJ, Komadina R, Nardi G, Neugebauer E, Ozier Y, Riddez L, Schultz A, Vincent J-L, Rossaint R: Management of bleeding and coagulopathy following major trauma: an updated European guideline. Crit Care 2013, 17:R76.PubMedView Article
                                      13. American College of Surgeons Committee on Trauma: Advanced Trauma Life Support for Doctors (ATLS) Student Course Manual. 8th edition. Chicago, IL: American College of Surgeons; 2008.
                                      14. Barochia AV, Cui X, Vitberg D, Suffredini AF, O'Grady NP, Banks SM, Minneci P, Kern SJ, Danner RL, Natanson C, Eichacker PQ: Bundled care for septic shock: an analysis of clinical trials. Crit Care Med 2010, 38:668–678.PubMedView Article
                                      15. Levy MM, Dellinger RP, Townsend SR, Linde-Zwirble WT, Marshall JC, Bion J, Schorr C, Artigas A, Ramsay G, Beale R, Parker MM, Gerlach H, Reinhart K, Silva E, Harvey M, Regan S, Angus DC, Surviving Sepsis Campaign: The Surviving Sepsis Campaign: results of an international guideline-based performance improvement program targeting severe sepsis. Crit Care Med 2010, 38:367–374.PubMedView Article

                                      Copyright

                                      © BioMed Central Ltd 2013