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Table 5 Suggested management bundles

From: The European guideline on management of major bleeding and coagulopathy following trauma: fourth edition

Pre-hospital bundle Intra-hospital bundle Coagulation bundle
• Pre-hospital time minimised
• Tourniquet employed in case of life-threatening bleeding from extremities
• Damage control resuscitation concept applied
• Trauma patient transferred directly to an adequate trauma specialty centre
• Full blood count, prothrombin time, fibrinogen, calcium, viscoelastic testing, lactate, BE and pH assessed within the first 15 min
• Immediate intervention applied in patients with haemorrhagic shock and an identified source of bleeding unless initial resuscitation measures are successful
• Immediate further investigation undertaken using focused assessment with sonography for trauma (FAST), computed tomography (CT) or immediate surgery if massive intra-abdominal bleeding is present in patients presenting with haemorrhagic shock and an unidentified source of bleeding
• Damage control surgery concept applied if shock or coagulopathy are present
• Damage control resuscitation concept continued until the bleeding source is identified and controlled
• Restrictive erythrocyte transfusion strategy (haemoglobin 7–9 g/dl) applied
• Tranexamic acid administered as early as possible
• Acidosis, hypothermia and hypocalcaemia treated
• Fibrinogen maintained at 1.5–2 g/l
• Platelets maintained at >100 × 109/l
• Prothrombin complex concentrate administered in patients pre-treated with warfarin or direct-acting oral coagulants (until antidotes are available)