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.
Injuries worldwide cause more than 16,000 deaths per day . 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 [2–4], 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  and the Surviving Sepsis Campaign launched in 2002  - 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  and developed guidelines for the management of the bleeding trauma patient, which have been updated at 3-year intervals [10–12]. 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 , 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 .
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 . 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.
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.
Support and manuscript preparation was provided by Physicians World Europe GmbH (Mannheim, Germany) supported by an unrestricted grant from CSL Behring GmbH (Marburg, Germany).
Department of Anaesthesiology, University Hospital Aachen, RWTH Aachen University
Department of Trauma and Orthopaedic Surgery, University of Witten/Herdecke, Cologne-Merheim Medical Centre
Faculty of Medicine in Hradec Králové, Department of Anaesthesiology and Intensive Care Medicine, University Hospital Hradec Králové
Department of Anesthesia, Pain Management and Perioperative Medicine, Dalhousie University
Accident and Emergency Department, University of Leicester
Department of Anaesthesia and Intensive Care, University of Paris XI, Faculté de Médecine Paris-Sud
Department of Emergency and Critical Care Medicine, University Hospital Virgen de las Nieves
Department of Cardiac Anaesthesia and Intensive Care, C. C. Iliescu Emergency Institute of Cardiovascular Diseases
Guy’s & St Thomas’ Foundation Trust
Department of Traumatology, General and Teaching Hospital Celje
Department of Trauma and Orthopaedic Surgery, University of Witten/Herdecke, Cologne-Merheim Medical Centre
Shock and Trauma Centre, S. Camillo Hospital
Institute for Research in Operative Medicine (IFOM), Witten/Herdecke University
Division of Anaesthesia, Intensive Care and Emergency Medicine, Brest University Hospital, Boulevard Tanguy Prigent
Department of Surgery and Trauma, Karolinska University Hospital
Ludwig-Boltzmann-Institute for Experimental and Clinical Traumatology, Lorenz Boehler Trauma Centre
Jean-Louis Vincent, Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles
Institute of Anaesthesiology, University Hospital Zurich
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