Stop the bleed " - Prehospital bleeding control in patients with multiple and/or severe injuries - A systematic review and clinical practice guideline - A systematic review and clinical practice guideline.

Abstract

Purpose: Our aim was to develop new evidence-based and consensus-based recommendations for bleeding control in patients with multiple and/or severe injuries in the prehospital setting. This guideline topic is part of the 2022 update of the German Guideline on the Treatment of Patients with Multiple and/or Severe Injuries.

Methods: MEDLINE and Embase were systematically searched until June 2021. Further literature reports were obtained from clinical experts. Randomised controlled trials, prospective cohort studies, and comparative registry studies were included if they compared interventions for bleeding control in the prehospital setting using manual pressure, haemostatic agents, tourniquets, pelvic stabilisation, or traction splints in patients with multiple and/or severe injuries. We considered patient-relevant clinical outcomes such as mortality and bleeding control. Transfusion requirements and haemodynamic stability were surrogate outcomes. Risk of bias was assessed using NICE 2012 checklists. The evidence was synthesised narratively, and expert consensus was used to develop recommendations and determine their strength.

Results: Fifteen studies were identified. Interventions covered were pelvic binders (n = 4 studies), pressure dressings (n = 1), tourniquets (n = 6), traction splints (n = 1), haemostatic agents (n = 3), and nasal balloon catheters (n = 1). Fourteen new recommendations were developed. All achieved strong consensus.

Conclusion: Bleeding control is the basic objective of treatment. This can be easily justified based on empirical evidence. There is, however, a lack of reliable and high-quality studies that assess and compare methods for bleeding control in patients with multiple and/or severe injuries. The guideline provides reasonable and practical recommendations (although mostly with a low grade of recommendation) and also reveals several open research questions that can hopefully be answered when the guideline is revised again.