Prehospital coagulation management and fluid replacement therapy in patients with multiple and/or severe injuries – A systematic review and clinical practice guideline update

The following key recommendations are made. Fluid replacement therapy should be initiated in severely injured patients. In patients with uncontrolled bleeding, fluid replacement therapy should be limited (MAP of 65 mmHg, SBP of 80 mmHg) in order to maintain minimum haemodynamic stability while not increasing blood loss. In hypotensive patients with suspected isolated or concomitant significant traumatic brain injury, the objective of fluid replacement should be to maintain normal blood pressure (MAP of 85 mmHg, SBP of 110 mmHg). Intravenous access is used in trauma patients. If intravenous access cannot be achieved in trauma patients, intraosseous access is used for the delivery of fluids and medications. If there are no signs and symptoms of volume depletion, fluid replacement therapy should not be provided. If the administration of a sufficient volume of fluids fails to achieve adequate blood pressure in a polytrauma patient, the titrated use of vasopressors for circulatory support may be considered. The lethal triad of hypothermia, acidosis, and coagulopathy should be addressed at the prehospital stage. One gram of tranexamic acid should be administered in cases of existing or imminent haemorrhagic shock. The administration of fibrinogen may also be considered in cases of uncontrollable bleeding, as may the administration of erythrocyte and plasma concentrates.