Advanced Trauma Life Support (ATLS): Major Haemorrhage Protocol & Anatomical Management

Critical ATLS: Mastering the Major Haemorrhage Protocol

Introduction & Epidemiology

Major haemorrhage remains a leading cause of preventable death in trauma. The Major Haemorrhage Protocol (MHP), often integrated within Advanced Trauma Life Support (ATLS) principles, represents a multidisciplinary, systematic approach to rapidly identify, manage, and definitively control severe bleeding. Haemorrhagic shock progression from Class II to Class IV is characterized by escalating physiological derangements, culminating in the lethal triad of coagulopathy, acidosis, and hypothermia. Early recognition and aggressive intervention are paramount to mitigating these cascades.

Epidemiologically, trauma accounts for an estimated 5.8 million deaths annually worldwide. Of these, uncontrolled haemorrhage contributes to 30-40% of early trauma mortalities and up to 50% of deaths within the first 24 hours. Penetrating injuries, high-energy blunt trauma, and pelvic fractures are particularly associated with significant blood loss. The mean blood loss in patients with major trauma can exceed several litres, necessitating rapid blood product administration. The timely activation and efficient execution of an MHP have been consistently shown to improve patient outcomes, reducing mortality, the incidence of multiple organ dysfunction syndrome (MODS), and transfusion requirements. The goal is not merely to transfuse but to achieve haemostatic resuscitation and definitive haemorrhage control while preventing iatrogenic complications.

Surgical Anatomy & Biomechanics

Understanding the potential sources of major haemorrhage in trauma requires a comprehensive grasp of surgical anatomy and the biomechanics of injury patterns. Haemorrhage can originate from five primary anatomical compartments: external, chest, abdomen, pelvis, and long bones (thighs).

Anatomical Compartments of Haemorrhage

• External:
  • Anatomy: Superficial arterial and venous structures (e.g., femoral artery/vein, brachial artery/vein, superficial temporal artery, scalp lacerations with extensive vascularity).
  • Biomechanics: Direct transection or laceration from penetrating trauma (stabbings, gunshot wounds), degloving injuries, or severe open fractures. Pressure application and tourniquet placement are the primary external control methods.
• Chest (Thoracic Haemorrhage):
  • Anatomy: Intercostal arteries and veins, internal mammary arteries, pulmonary vessels (hilar vessels, parenchymal lacerations), great vessels (aorta, superior/inferior vena cava), cardiac chambers.
  • Biomechanics: Blunt trauma (rib fractures with associated vascular injury, aortic dissection/rupture, cardiac contusion/rupture) or penetrating trauma (laceration of lung parenchyma, intercostal vessels, great vessels, or heart). Accumulation of blood in the pleural space (haemothorax) or pericardial sac (cardiac tamponade) can severely compromise cardiopulmonary function.
• Abdomen (Intra-abdominal Haemorrhage):
  • Anatomy: Solid organ injuries (spleen, liver, kidney, pancreas), mesenteric vessels, retroperitoneal vessels (aorta, vena cava, iliac vessels), pelvic vessels.
  • Biomechanics: Blunt trauma (deceleration injuries causing liver/spleen lacerations, avulsion of mesentery) or penetrating trauma. The retroperitoneum can accommodate large volumes of blood before external signs of shock become evident. Liver and splenic injuries are common sources, often exacerbated by underlying coagulopathy.
• Pelvis (Pelvic Haemorrhage):
  • Anatomy: Internal iliac arterial and venous branches (superior/inferior gluteal, obturator, internal pudendal), sacral venous plexus, cancellous bone of the iliac wings, sacrum, and pubic rami.
  • Biomechanics: High-energy blunt trauma resulting in pelvic ring disruption. Venous plexus and cancellous bone bleeding are common, non-coagulable sources, leading to significant, often occult, blood loss. Arterial bleeding from branches of the internal iliac artery can be particularly severe and is often amenable to embolization.
• Long Bones (Thigh/Femur):
  • Anatomy: Femoral artery/vein, deep femoral artery/vein, significant intramedullary canal volume, and extensive muscle compartment vascularity.
  • Biomechanics: Femoral shaft fractures, particularly open fractures, can result in 1.5-2 litres of blood loss per fractured femur due to direct vascular injury, intramedullary bleeding, and haematoma expansion within the large thigh compartment. Bilateral femoral fractures can rapidly lead to exsanguination.

Biomechanics of Haemorrhagic Shock and Coagulopathy

Understanding the physiological biomechanics of how the body responds to and is overwhelmed by haemorrhage is critical.
* Compensatory Mechanisms: Initial vasoconstriction, increased heart rate, and fluid shifts from the interstitial space attempt to maintain cardiac output and tissue perfusion.
* Decompensation: As blood loss continues, these mechanisms fail. Hypoperfusion leads to anaerobic metabolism, lactic acidosis, and endothelial damage.
* Trauma-Induced Coagulopathy (TIC): This is a complex, multifactorial phenomenon triggered by shock, acidosis, hypothermia, and haemodilution. It involves platelet dysfunction, depletion of clotting factors, hyperfibrinolysis, and endothelial activation. TIC significantly exacerbates bleeding, creating a vicious cycle.
* Permissive Hypotension: The concept of maintaining a systolic blood pressure target (e.g., 80-90 mmHg) in actively bleeding patients without head injury allows for some degree of hypoperfusion to prevent "popping the clot" until surgical control is achieved. Over-resuscitation with crystalloids can worsen coagulopathy and lead to abdominal compartment syndrome.

Indications & Contraindications

Indications for Major Haemorrhage Protocol Activation

The decision to activate an MHP is a critical early step, requiring rapid assessment and clinical judgment. Indications are primarily clinical and laboratory-based:

• Clinical Criteria:
  • Haemodynamic instability: Systolic Blood Pressure (SBP) <90 mmHg or Mean Arterial Pressure (MAP) <65 mmHg, despite initial fluid bolus.
  • Heart Rate (HR) >120 bpm (persistent tachycardia).
  • Signs of hypoperfusion: Altered mental status, cool peripheries, delayed capillary refill.
  • Ongoing visible blood loss: Significant external bleeding, expanding haematoma.
  • Mechanism of injury suggesting major haemorrhage: High-energy blunt trauma, penetrating chest/abdominal trauma, multiple long bone fractures, unstable pelvic fracture.
• Laboratory Criteria (early indicators):
  • Base Deficit (BD) ≥6 mmol/L.
  • Lactate >4 mmol/L.
  • International Normalized Ratio (INR) ≥1.5.
  • Haemoglobin (Hb) <70-80 g/L (though this may be delayed in acute haemorrhage).
  • Rapid transfusion requirement: >3 units packed red blood cells (PRBCs) within the first hour, or anticipated need for >10 units PRBCs within 24 hours (massive transfusion criteria).
• Imaging Criteria:
  • Positive Focused Assessment with Sonography for Trauma (FAST) scan demonstrating significant free fluid in the peritoneum or pericardium in a haemodynamically unstable patient.
  • Computed Tomography (CT) scan revealing major organ injury with active extravasation or large haematoma.

Contraindications

True contraindications to initiating the MHP are rare, as it is a life-saving protocol for actively bleeding patients. However, certain considerations influence specific interventions within the protocol.

• Absence of Active Haemorrhage: The MHP is not indicated for normovolemic patients or those with controlled bleeding.
• Advanced Directives/End-of-Life Wishes: In patients with clearly documented "Do Not Resuscitate" (DNR) or other advanced care directives, the MHP may not be pursued, though this requires careful ethical consideration and family communication.
• Isolated Head Injury with No Extracranial Haemorrhage: While head injury can cause elevated intracranial pressure and cerebral ischemia, the MHP is specifically for extracranial haemorrhage. Permissive hypotension is generally contraindicated in severe traumatic brain injury (TBI) where cerebral perfusion pressure must be maintained. A balanced approach is needed for poly-trauma patients with TBI and major haemorrhage.

Operative vs. Non-Operative Indications in Haemorrhagic Trauma

Pre-Operative Planning & Patient Positioning

"Pre-operative planning" in the context of major haemorrhage often occurs concurrently with initial resuscitation and diagnostic evaluation. It involves a rapid, systematic approach under immense time pressure, often transitioning seamlessly into operative intervention.

Pre-Operative Planning (Concurrent Resuscitation and Assessment)

1. Massive Transfusion Protocol (MTP) Activation: Immediate activation based on clinical and laboratory triggers. This initiates rapid blood product delivery (PRBCs, FFP, platelets) in pre-defined ratios (e.g., 1:1:1 or 2:1:1 PRBC:FFP:platelets) to combat TIC and replenish oxygen-carrying capacity.
2. Airway Management: Secure airway with endotracheal intubation if Glasgow Coma Scale (GCS) <8, impending airway compromise, or significant respiratory distress due to shock.
3. Vascular Access: Establish at least two large-bore (14-16 gauge) intravenous lines, preferably peripheral. Central venous access (femoral, subclavian, internal jugular) may be needed for rapid infusion or CVP monitoring. Intraosseous (IO) access is a rapid alternative in extremis.
4. Diagnostic Modalities:
   • FAST Scan: Bedside ultrasound to rapidly identify free fluid in the pericardium or peritoneum, guiding immediate intervention.
   • X-rays: Chest X-ray (CXR) for haemothorax, pneumothorax, mediastinal widening. Pelvic X-ray (PXR) for pelvic ring disruption.
   • Computed Tomography (CT) Scan: If haemodynamically stable enough, a whole-body CT scan is the gold standard for identifying injury patterns, active extravasation, and guiding definitive management. Unstable patients should proceed directly to the operating room or angiography suite.
5. Haemostatic Resuscitation:
   • Permissive Hypotension: Target SBP 80-90 mmHg (MAP 60-65 mmHg) in patients without severe TBI until bleeding control.
   • Tranexamic Acid (TXA): Administer 1g IV bolus within 3 hours of injury, followed by 1g infusion over 8 hours (CRASH-2 trial evidence).
   • Calcium Supplementation: Administer calcium chloride/gluconate to counteract citrate toxicity from blood products, preventing hypocalcaemia and subsequent myocardial dysfunction and coagulopathy.
   • Correction of Acidosis/Hypothermia: Actively warm the patient (warm blankets, fluid warmers, warmed irrigation) and optimize ventilation to correct acidosis, as both severely impair clotting.
6. Surgical Team Preparation: Call for relevant surgical teams (General Surgery, Orthopaedics, Vascular, Thoracic, Interventional Radiology), anaesthesia, and critical care teams.
7. Definitive Haemostasis Strategy: Based on identified bleeding sources, plan for:
   • Direct pressure/Tourniquets: For extremity bleeding.
   • Pelvic Binder: For unstable pelvic fractures.
   • Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA): A temporizing measure for non-compressible torso haemorrhage below the diaphragm.
   • Damage Control Surgery (DCS): For ongoing intra-abdominal or intra-thoracic haemorrhage.

Patient Positioning

Patient positioning for surgical intervention in major haemorrhage must be rapid, adaptable, and consider potential multi-system injuries.

• Supine Position: This is the default position for nearly all initial trauma interventions (laparotomy, thoracotomy, REBOA, pelvic external fixation).
  • Arms: Often abducted and taped to arm boards to allow access to the lateral chest wall, abdomen, and for IV access.
  • Legs: Typically straight for access to groin (femoral artery for REBOA, vascular repair), pelvis, and long bones.
  • Pads: Minimal padding is used acutely; focus is on rapid access. Pressure points are addressed as resuscitation permits.
• Imaging Compatibility: The bed must be radiolucent for intra-operative fluoroscopy (e.g., for REBOA placement, pelvic external fixation, arterial embolization).
• Temperature Management: Forced-air warming blankets should be applied aggressively to minimize hypothermia, which exacerbates coagulopathy.
• Monitoring: Comprehensive monitoring (ECG, pulse oximetry, capnography, invasive arterial line, central venous catheter) is essential.

Detailed Surgical Approach / Technique

The "surgical approach" in major haemorrhage is often a sequence of damage control interventions aimed at rapid bleeding control and physiological stabilization, rather than definitive repair. The overarching principle is "stop the bleeding, fix the physiology."

1. Initial Resuscitation & External Haemorrhage Control

• Direct Pressure: Apply firm, sustained pressure to accessible external bleeding points.
• Tourniquets: Apply promptly and proximally to extremity injuries with uncontrolled arterial haemorrhage. Ensure proper application (high and tight) and document application time.
• Pelvic Binder/Sheet Wrap: For suspected or confirmed unstable pelvic fractures, apply a pelvic binder or bed sheet wrapped circumferentially around the greater trochanters and cinched tightly to reduce pelvic volume and tamponade bleeding from the sacral venous plexus and cancellous bone.

2. Resuscitative Thoracotomy (Emergency Department or OR)

• Indications: Penetrating thoracic trauma with loss of vital signs (pulseless electrical activity or asystole) within 10-15 minutes of arrival, especially with signs of life pre-hospital. Also for massive haemothorax with ongoing bleeding, cardiac tamponade unresponsive to pericardiocentesis.
• Approach: Left anterolateral thoracotomy (4th or 5th intercostal space). Incision from sternal edge laterally to mid-axillary line.
  • Dissection: Incise skin, subcutaneous tissue, pectoralis major, intercostal muscles. Rib spreader inserted.
  • Technique:
    • Clam Shell Incision: If cross-chest injury or bilateral haemorrhage is suspected, extend the incision across the sternum (transecting internal mammary arteries).
    • Pericardiotomy: Incise the pericardium anterior to the phrenic nerve to relieve cardiac tamponade, evacuate clot, and repair cardiac wounds (fingercotomy, staples, sutures).
    • Aortic Cross-Clamping: Temporarily clamp the descending thoracic aorta to redirect blood flow to the brain and heart, improving myocardial perfusion and reducing infra-diaphragmatic bleeding.
    • Pulmonary Hilar Clamping: For massive pulmonary parenchymal haemorrhage, temporarily clamp the hilum.
    • Massive Haemothorax: Evacuate clot, ligate intercostal vessels, repair lung lacerations (stapling, suture).
• Post-Thoracotomy: Chest tube insertion, closure.

3. Damage Control Laparotomy (DCL)

• Indications: Haemodynamically unstable patients with intra-abdominal haemorrhage unresponsive to resuscitation, suspected major vascular injury, ongoing severe contamination, or abdominal compartment syndrome.
• Approach: Midline laparotomy incision (xiphoid to pubis).
  • Dissection: Rapid skin, subcutaneous tissue, fascia, peritoneum incision.
  • Technique (4 Phases of DCS):
    • Phase 1: Haemorrhage Control & Contamination Control:
      • Rapid Exploration: Identify bleeding source.
      • Packing: Aggressive packing with laparotomy sponges around liver, spleen, pelvis, and retroperitoneum to tamponade bleeding. Consider specific manoeuvres like Pringle manoeuvre for liver hilum.
      • Vessel Ligation/Repair: Ligation of smaller vessels; shunting or temporary repair for major vascular injuries (e.g., aorta, vena cava, iliacs).
      • Bowel Injury: Temporary control of contamination (staple ends, oversew, divert). No definitive anastomoses.
    • Phase 2: Temporary Abdominal Closure:
      • Abdomen left open (laparostomy) to allow for re-exploration, prevent abdominal compartment syndrome, and manage swelling. Various temporary closure techniques: vacuum-assisted closure (VAC), Bogota bag, skin-only closure.
    • Phase 3: Resuscitation in ICU: Aggressive correction of acidosis, hypothermia, and coagulopathy.
    • Phase 4: Definitive Repair: Return to OR in 24-48 hours for definitive repair of injuries, pack removal, and fascial closure once physiological stability achieved.

4. Pelvic External Fixation & Angioembolization

• Indications: Unstable pelvic ring fractures with ongoing haemorrhage, haemodynamic instability despite resuscitation and pelvic binder.
• External Fixation (Orthopaedic Surgeon):
  • Approach: Percutaneous placement of pins into the iliac crests (anterior superior iliac spine, ASIS) or supra-acetabular region, connected by a rigid frame.
  • Technique: Under fluoroscopic guidance, pins are driven into the ilium. The frame is applied to stabilize the anterior pelvic ring and reduce pelvic volume, indirectly tamponading venous and cancellous bone bleeding.
• Angioembolization (Interventional Radiologist):
  • Indications: Documented or strongly suspected arterial pelvic bleeding (often persistent haemorrhage despite mechanical stabilization).
  • Approach: Femoral artery access.
  • Technique: Selective catheterization of the internal iliac artery and its branches to identify bleeding points, followed by embolization with coils, Gelfoam, or other embolic agents. This targets arterial sources that external fixation cannot control.

5. Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA)

• Indications: Non-compressible torso haemorrhage below the diaphragm (Zone 1 or Zone 3), refractory haemorrhagic shock, as a temporizing measure to allow time for resuscitation or transport to definitive care.
• Approach: Femoral artery access (often surgical cut-down to minimize complications).
• Technique: A balloon-tipped catheter is advanced into the aorta.
  • Zone 1 (Thoracic Aorta): For infra-diaphragmatic haemorrhage (e.g., liver, spleen, retroperitoneum, major pelvic vessel). Balloon inflated above the coeliac axis. Provides global haemorrhage control for infra-diaphragmatic bleeding.
  • Zone 3 (Infra-renal Aorta): For pelvic or proximal lower extremity haemorrhage. Balloon inflated just above the aortic bifurcation. Maintains visceral perfusion while controlling distal bleeding.
• Key Considerations: REBOA is a temporary measure. Ischaemia time must be minimized (<30-60 minutes). Risk of distal ischaemia, aortic injury, access site complications.

6. Long Bone Fracture Stabilization (Damage Control Orthopaedics)

• Indications: Femoral, tibial, or humeral shaft fractures causing significant bleeding, particularly in poly-trauma patients with MHP activation.
• Approach: External fixation is preferred in the initial damage control setting.
  • Technique: Rapid application of unilateral or biplanar external fixators across the fracture site. This stabilizes the fracture, reduces soft tissue motion, and tamponades ongoing bleeding, converting a dynamic haematoma into a static one.
• Goal: Not definitive fixation, but rapid stabilization to reduce blood loss and allow physiological optimization. Definitive internal fixation (e.g., intramedullary nailing) is performed later once the patient is stable.

Complications & Management

Complications following major haemorrhage and its management are frequent and can be severe, reflecting the critical nature of the initial injury and the aggressive interventions required. Prevention and early recognition are key.

Table of Common Complications, Incidence, and Salvage Strategies

Post-Operative Rehabilitation Protocols

Post-operative rehabilitation in the context of major haemorrhage management begins in the Intensive Care Unit (ICU) and follows a damage control approach, gradually transitioning towards definitive care and functional recovery. The initial focus is on physiological stabilization, followed by early mobilization and progressive functional restoration.

1. ICU Phase (Physiological Stabilization & Early Mobility)

• Fluid & Electrolyte Management: Meticulous balance to prevent oedema, organ dysfunction, and manage ongoing losses.
• Respiratory Support: Weaning from mechanical ventilation as clinically appropriate. Early extubation is prioritized to reduce ventilator-associated pneumonia risk.
• Cardiovascular Support: Weaning from vasopressors, optimizing cardiac output, continuous haemodynamic monitoring.
• Temperature Control: Maintain normothermia to optimize metabolism and coagulation.
• Pain Management: Multimodal analgesia including regional blocks, IV opioids, and non-opioid adjuncts to facilitate patient comfort and mobilization.
• Nutrition: Early enteral nutrition (within 24-48 hours) via nasogastric or nasojejunal tube to support gut integrity, immune function, and wound healing. Parenteral nutrition if enteral is contraindicated.
• Prophylaxis:
  • Venous Thromboembolism (VTE): Pharmacological prophylaxis (LMWH, fondaparinux) initiated as soon as bleeding risk is controlled. Mechanical prophylaxis (sequential compression devices) always used.
  • Stress Ulcer: Proton pump inhibitors (PPIs) or H2 blockers.
• Early Mobilization:
  • Within 24-48 hours: Passive range of motion (PROM) exercises, bed mobility, sitting at edge of bed.
  • Progressive: Active range of motion (AROM), transfer training (bed to chair), standing, and short walks as soon as haemodynamic stability and pain control permit. This is crucial for preventing deconditioning, respiratory complications, and VTE.
• Wound Care: Meticulous care of surgical wounds, particularly temporary abdominal closures (VAC dressings). Monitoring for infection.
• Damage Control Orthopaedics (DCO) Consideration: If external fixators are in place, maintain pin site care. Plan for definitive internal fixation once physiologically optimized (often 3-14 days post-injury).

2. Ward Phase (Progressive Mobilization & Functional Recovery)

• Ambulation: Progressive increase in ambulation distance and independence, often with physical therapy assistance. Weight-bearing restrictions for orthopedic injuries are strictly adhered to.
• Occupational Therapy: Assessment and training for activities of daily living (ADLs), adaptive equipment, and cognitive support if needed.
• Pain Management Transition: Oral analgesics, regional pain blocks, and non-pharmacological methods.
• Nutrition: Oral diet advancement, nutritional counselling.
• Psychological Support: Screening for post-traumatic stress disorder (PTSD), depression, anxiety. Early involvement of psychiatry/psychology.
• Splinting/Bracing: For specific injuries to protect repairs or manage contractures.
• Patient Education: Comprehensive education on injury, surgical procedures, expected recovery trajectory, warning signs, and activity restrictions.

3. Outpatient/Community Phase (Long-term Rehabilitation)

• Physical Therapy: Structured rehabilitation programs tailored to specific injuries (e.g., gait training, strengthening, balance, joint specific ROM).
• Occupational Therapy: Return to work/hobbies assessments, cognitive rehabilitation.
• Follow-up: Regular follow-up with orthopedic, trauma surgery, and other specialist teams to monitor recovery, identify complications, and plan for any secondary procedures.
• Psychosocial Reintegration: Continued psychological support, support groups, vocational rehabilitation.
• Pharmacological Management: Long-term pain management, anti-coagulation if indicated, and other medications.

Summary of Key Literature / Guidelines

The management of major haemorrhage is continuously evolving, driven by evidence-based medicine and multidisciplinary consensus. Key guidelines and landmark studies inform current practice.

1. Advanced Trauma Life Support (ATLS)

• Publisher: American College of Surgeons Committee on Trauma (ACS COT).
• Core Principles: The fundamental framework for the initial assessment and management of trauma patients. Emphasizes primary survey (ABCDE), secondary survey, and definitive care planning. The MHP integrates seamlessly into the "C" (circulation) of the primary survey, advocating for rapid identification and control of bleeding. ATLS emphasizes the "golden hour" for critical interventions.
• Relevance: Mandates early recognition of shock, rapid vascular access, fluid resuscitation with blood products, and timely transfer to definitive care.

2. European Guidelines on Management of Major Bleeding and Coagulopathy Following Trauma (European Trauma Course / European Society of Anaesthesiology and Intensive Care)

• Key Focus: Comprehensive, evidence-based recommendations covering pre-hospital care, resuscitation strategies, haemostatic management, specific surgical and interventional radiology techniques, and critical care.
• Highlights:
  • Tranexamic Acid (TXA): Strong recommendation for early administration (within 3 hours of injury) in bleeding trauma patients. Supported by the CRASH-2 and MATTERs trials.
  • Permissive Hypotension: Recommended in patients without TBI until bleeding control.
  • Massive Transfusion Protocol (MTP): Emphasizes balanced transfusion ratios (PRBC:FFP:platelets), ideally guided by viscoelastic haemostatic assays (TEG/ROTEM).
  • Calcium: Proactive administration to prevent hypocalcaemia from blood products.
  • Early Bleeding Control: Advocates for immediate surgical or interventional radiological control of haemorrhage.
  • REBOA: Provides recommendations for its use as a temporizing measure in specific circumstances.
  • Temperature Management: Aggressive warming to prevent hypothermia.

3. CRASH-2 Trial (Clinical Randomisation of an Antifibrinolytic in Significant Haemorrhage)

• Publication: The Lancet, 2010.
• Findings: Demonstrated a significant reduction in mortality (all-cause and bleeding-related) with the administration of TXA in trauma patients with significant haemorrhage if given within 3 hours of injury. No increase in thrombotic events.
• Impact: Revolutionized haemostatic therapy in trauma, making TXA a standard of care.

4. PROPPR Trial (Pragmatic, Randomized Optimal Platelet and Plasma Ratios)

• Publication: JAMA, 2015.
• Findings: Compared a high ratio (1:1:1 PRBC:FFP:platelets) to a lower ratio (2:1:1) in severely injured trauma patients requiring massive transfusion. While there was no significant difference in 24-hour or 30-day mortality, the high-ratio group showed improved haemostasis and reduced early mortality from exsanguination.
• Impact: Provided strong evidence supporting balanced transfusion strategies and influenced many institutional MTPs towards higher ratios of plasma and platelets.

5. Eastern Association for the Surgery of Trauma (EAST) Guidelines

• Scope: Publishes numerous practice management guidelines (PMG) relevant to trauma, including those on splenic trauma, hepatic trauma, pelvic fractures, and damage control surgery.
• Relevance: Offers specific, evidence-based recommendations for the surgical management of various injuries contributing to major haemorrhage.

6. World Health Organization (WHO) Guidelines for Trauma Care

• Focus: Global recommendations for improving trauma care systems, especially in low-resource settings.
• Highlights: Emphasizes basic principles of haemorrhage control, appropriate transfer protocols, and essential equipment.

These foundational documents underscore the importance of a coordinated, multidisciplinary, and evidence-based approach to major haemorrhage. The evolving landscape of trauma care continues to refine these protocols, with ongoing research into new haemostatic agents, imaging modalities, and surgical techniques. Orthopedic surgeons play a pivotal role in this system, particularly in the rapid mechanical stabilization of fractures causing significant blood loss and in the ultimate definitive reconstruction.