Context: haemorrhagic shock after trauma
Haemorrhagic shock is one of the most common preventable causes of death after trauma. Definitive control of the bleeding source is rarely possible in the prehospital setting. Prehospital emergency physician management therefore focuses on three points:
- control external haemorrhage immediately
- avoid further impairment of coagulation through dilution, hypothermia and acidosis
- do not delay transport to a hospital with surgical or interventional haemostasis capability
The sixth edition of the European Guideline on Management of Major Bleeding and Coagulopathy following Trauma (Rossaint et al., 2023) is the key reference. Specific target values not stated here should be taken from the original guideline.
Stop critical haemorrhage first
Spurting or massive external haemorrhage takes priority over all other measures. Many algorithms therefore place it before the classic ABCDE approach ("cABCDE" or "<C>ABCDE"). A stepwise approach has proven effective in the prehospital setting:
- Direct manual pressure and a pressure dressing as the first measure
- Tourniquet for life-threatening limb haemorrhage that cannot be controlled by pressure. Document the time of application and hand it over to the receiving team.
- Haemostatic dressings and wound packing for bleeding at the junction between trunk and limb (junctional), where a tourniquet cannot be applied
- Pelvic binder for suspected unstable pelvic injury with haemodynamic instability
- Axial realignment and splinting of long bones to limit blood loss into the soft tissues
Non-compressible haemorrhage in the thorax, abdomen and retroperitoneum cannot be stopped prehospital. Here, a short time to definitive haemostasis is the most effective measure. The receiving hospital should be pre-alerted early, ideally with a note on possible massive transfusion requirements.
Fluid strategy and permissive hypotension
Principle
Permissive hypotension refers to a deliberately lower target blood pressure until surgical or interventional haemorrhage control is achieved. It is based on two considerations:
- Aggressively raising blood pressure may dislodge freshly formed clots and increase bleeding.
- Large volumes of crystalloid dilute coagulation factors and platelets and promote hypothermia and acidosis.
The European Trauma Guideline 2023 recommends a lowered systolic or mean arterial pressure target in active bleeding without traumatic brain injury until haemorrhage control. The specific target values should be taken from the original guideline and aligned with local protocols.
Limits of permissive hypotension
- Traumatic brain injury: Maintaining cerebral perfusion pressure takes priority. The guideline specifies a higher blood pressure target; permissive hypotension is not intended.
- Older patients and chronic arterial hypertension: Tolerance of hypotension may be lower. The target should be weighed individually; evidence for these groups is limited.
- Time factor: The concept assumes that definitive haemostasis is achieved promptly. With long transport times, the risk of organ hypoperfusion increases.
Practical implementation
- Give fluids titrated and goal-directed, not in fixed volumes
- Use crystalloids sparingly. Use blood products available prehospital according to local protocol.
- In life-threatening hypotension despite fluid administration, a vasopressor is temporarily acceptable according to the European Trauma Guideline (dosage according to the current guideline and summary of product characteristics).
- Actively prevent hypothermia: heat preservation, warmed infusions and protection from cooling from the scene onwards
Tranexamic acid in trauma
Mechanism of action and indication
Tranexamic acid is an antifibrinolytic (lysine analogue). It inhibits the hyperfibrinolysis activated early in severe trauma. The European Trauma Guideline 2023 recommends administration in trauma patients who are bleeding or at risk of significant bleeding as early as possible, ideally already in the prehospital setting.
Administration is explicitly not dependent on coagulation or viscoelastic test results. This is crucial prehospital, as such diagnostics are not available there.
Adult dosage (Rossaint et al. 2023)
| Phase | Dose | Note |
|---|---|---|
| Bolus | 1 g IV over 10 min | as early as possible, within 3 h of injury; 100 mg/ml → 10 ml |
| Maintenance | 1 g IV over 8 h | e.g. 1 g/50 ml via syringe driver at 6.25 ml/h |
The 3-hour window
A first dose should not be started later than 3 h after injury. In CRASH-2, late administration showed no benefit but an increase in deaths due to bleeding. In the prehospital setting this means:
- Establish and document the time of injury as precisely as possible
- Hand over the time of administration to the trauma bay team so that the maintenance dose follows correctly and duplicate dosing is avoided
Traumatic brain injury
In CRASH-3 (Lancet 2019), tranexamic acid reduced head injury-related deaths in mild to moderate TBI (GCS 9–15). The regimen used was 1 g IV over 10 min, then 1 g over 8 h, within 3 h of injury. No benefit was demonstrated in severe TBI (GCS 3–8). This is a trial regimen, not a statement from the summary of product characteristics.
Children
According to the ERC Guidelines 2025 (Paediatric Life Support), the following applies to all children requiring transfusion after trauma or with life-threatening haemorrhage:
- Bolus: 15–20 mg/kg IV over 10 min, max. 1000 mg, as early as possible, at the latest within 3 h
- Infusion: 2 mg/kg/h over at least 8 h or until bleeding stops. According to RCUK 2025, the infusion is max. 1 g; it is to be considered separately from the bolus.
- Examples: 10 kg body weight → 150–200 mg (1.5–2 ml) bolus, then 20 mg/h; 20 kg body weight → 300–400 mg (3–4 ml) bolus, then 40 mg/h
- From approx. 12 years of age or at adult body weight, the adult regimen applies.
Safety and contraindications
- Intravenous use only: Mix-ups with local anaesthetics during spinal anaesthesia have led to severe seizures and deaths. Never administer intrathecally, intraventricularly or intracerebrally; store ampoules separately.
- Inject slowly (approx. 1 ml/min). Too rapid administration can cause hypotension, which is particularly relevant in shock.
- Seizures may occur in a dose-dependent manner.
- Contraindications according to the summary of product characteristics: acute venous or arterial thrombosis, history of seizures, severe renal impairment (accumulation). In life-threatening haemorrhage, benefit must be weighed against risk.
Anticoagulated trauma patients
The use of anticoagulants should be specifically asked about prehospital and handed over, as it determines coagulation therapy in the trauma bay.
- Vitamin K antagonists: The European Trauma Guideline 2023 recommends prothrombin complex concentrate (PCC) and vitamin K (phytomenadione 5–10 mg slowly IV) early and in combination. The PCC dose depends on the INR and the summary of product characteristics of the product.
- Trauma without anticoagulant: PCC only with viscoelastic evidence of delayed coagulation initiation and normal fibrinogen. Prophylactic administration is not intended because of the risk of thromboembolism.
Practice checklist
- Stop critical external haemorrhage immediately: pressure, tourniquet, haemostatic agents, pelvic binder
- Give fluids restrictively and titrated; blood pressure target according to the European Trauma Guideline, higher target in TBI
- Tranexamic acid 1 g IV over 10 min, as early as possible and only within 3 h of injury
- Heat preservation from the outset
- Ask about anticoagulants; document times (injury, tourniquet, tranexamic acid)
- Pre-alert the receiving hospital early, keep on-scene and transport times short
References
- Rossaint R, Afshari A, Bouillon B et al. The European guideline on management of major bleeding and coagulopathy following trauma: sixth edition. Crit Care 2023;27:80.
- CRASH-3 trial collaborators. Effects of tranexamic acid on death, disability, vascular occlusive events and other morbidities in patients with acute traumatic brain injury (CRASH-3): a randomised, placebo-controlled trial. Lancet 2019;394:1713–1723.
- Djakow J, Turner NM, Skellett S et al. European Resuscitation Council Guidelines 2025 Paediatric Life Support. Resuscitation 2025;215 Suppl 1:110767.
- Resuscitation Council UK. Paediatric advanced life support algorithm – 2025 Resuscitation Guidelines (Fassungen 10/2025 und V2 11/2025) sowie Paediatric Life Support Guideline 2025 (Wiedergabe in Medscape: Paediatric Life Support – RCUK 2025 Guideline Summary).
This article does not replace clinical judgement in the individual case or the current summary of product characteristics and guidelines.
