A. Permissive hypotension
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목표 SBP : 80–90 mmHg (MAP 50–60 mmHg)
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severe TBI (GCS ≤ 8)시 SBP ≥ 80 mmHg 유지권장 (Grade 1C)
B. Vasopressors and inotropic agents
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life-threatening hypotension 시 fluid + vasopressor 사용 (Grade 1C)
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NEP 를 많이 사용
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Myocardial dysfunction 시 inotropic agent 사용(Grade 1C)
such as dobutamine or epinephrine
C. Type of fluid
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isotonic crystalloid solutions 으로 시작 (Grade 1A)
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balanced electrolyte solutions (Grade 1B)
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심한 뇌손상 시 Ringer’s lactate 같은 hypotonic solution은 피할 것 (Grade 1B)
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colloids 수액은 사용금기 (haemostasis 에 영향) (Grade 1C)
D. 출혈과 응고장애의 초기 처치-Antifibrinolytic agents
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출혈이나 상당한 출혈 위험이 있는 환자에게 TXA사용 권장
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손상 3시간 이내 투여
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loading dose of 1 g infused over 10 min
⇒ followed by an i.v. infusion of 1 g over 8 h. (Grade 1A)
E. Initial coagulation resuscitation
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대량출혈 예상환자에게 다음 중 하나의 전략 추천
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FFP or pathogen-inactivated FFP in a FFP:RBC ratio of at least 1:2 as needed. (Grade 1C)
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Fibrinogen concentrate and RBC. (Grade 1C)
Fibrinogen is the single coagulation factor that is affected more and earlier in association with trauma-induced coagulopathy.
Fibrinogen substitute
D2. Further goal-directed coagulation management
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We recommend that resuscitation measures be continued using a goal-directed strategy, guided by standard laboratory coagulation values and/or VEM. (Grade 1B)
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Standard laboratory coagulation value: PTT and PT/INR, Platelet count , Fibrinogen level
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Viscoelastic method(VEM): ROTEM, TEG
D3. FFP-based management
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If a FFP-based coagulation resuscitation strategy is used, we recommend that further use of FFP be guided by standard laboratory coagulation screening parameters (PT and/or APTT > 1.5 times normal and/or viscoelastic evidence of a coagulation factor deficiency). (Grade 1C)
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We recommend that FFP transfusion be avoided in patients without major bleeding. (Grade 1B)
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We recommend that the use of FFP be avoided for the treatment of hypofibrinogenaemia. (Grade 1C)
D4. Coagulation factor concentrate-based management
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If a CFC-based strategy is used, we recommend treatment with factor concentrates based on standard laboratory coagulation parameters and/or viscoelastic evidence of a functional coagulation factor deficiency. (Grade 1C)
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Provided that fibrinogen levels are normal, we suggest that PCC is administered to the bleeding patient based on evidence of delayed coagulation initiation using VEM. (Grade 2C)
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Prothrombin Complex Concentrates: concentrate of the vitamin K dependent factors (2, 7, 9, 10)
D5. Fibrinogen supplementation
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We recommend treatment with fibrinogen concentrate or cryoprecipitate if major bleeding is accompanied by hypofibrinogenaemia (viscoelastic signs of a functional fibrinogen deficit or a plasma Clauss fibrinogen level ≤ 1.5 g/L). (Grade 1C)
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We suggest an initial fibrinogen supplementation of 3–4 g. This is equivalent to 15–20 single-donor units of cryoprecipitate or 3–4 g fibrinogen concentrate. Repeat doses should be guided by VEM and laboratory assessment of fibrinogen levels. (Grade 2C)
D6. Platelets supplementation
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We recommend that platelets be administered to maintain a platelet count above 50 × 109 /L. (Grade 1C)
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We suggest maintenance of a platelet count above 100 × 109 /L in patients with ongoing bleeding and/or TBI. (Grade 2C)
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If administered, we suggest an initial dose of four to eight single platelet units or one aphaeresis pack. (Grade 2C)
E. Calcium
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We recommend that ionized calcium levels be monitored and maintained within the normal range during massive transfusion (Grade 1C)
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We suggest that the administration of calcium chloride to correct hypocalcemia (Grade 2C)
Anti thrombic agent reversal
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We recommend reversal of the effect of antithrombotic agents in patients with ongoing bleeding. (Grade 1C)
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1. VKAs
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2. Direct oral anticoagulants—FXa inhibitor
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3. Direct oral anticoagulants—Thrombin inhibitor
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4. Antiplatelet agents
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Once the antithrombotic agent has been reversed then the patient is at risk of thrombosis. Appropriate thromboprophylaxis should therefore be initiated as soon as possible after bleeding has been controlled.
Reversal of vitamin K-dependent oral anticoagulants
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In the bleeding trauma patient, we recommend the emergency reversal of vitamin K-dependent oral anticoagulants with the early use of both PCC and 5 mg i.v. phytomenadione (vitamin K1). (Grade 1A)
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Three therapeutic options: Vit K, PCC and FFP
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(Prothrombin Complex Concentrates)
Direct oral anticoagulants—factor Xa inhibitors- apixaban, edoxaban or rivaroxaban
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We suggest the measurement of plasma levels of oral direct anti-factor Xa agents in patients treated or suspected of being treated with one of these agents. (Grade 2C)
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We suggest that measurement of anti-Xa activity be calibrated for the specific agent. If measurement is not possible or available, we suggest that advice from an expert haematologist be sought. (Grade 2C)
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치명적인 출혈이 있는 경우, 특정 해독제가 준비될 때 까지 TXA 15 mg/kg (or 1 g) IV 투여와 PCC (25–50 U/kg) 사용을 고려한다 (Grade 2C)
DOAC—direct thrombin inhibitors
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We suggest the measurement of dabigatran plasma levels using diluted thrombin time in patients treated or suspected of being treated with dabigatran. (Grade 2C)
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If measurement is not possible or available, we suggest measurement of the standard thrombin time to allow a qualitative estimation of the presence of dabigatran. (Grade 2C)
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If bleeding is life-threatening in those receiving dabigatran, we recommend treatment with idarucizumab (5 g intravenously) (Grade 1B) and suggest treatment with TXA 15 mg/kg (or 1 g) intravenously. (Grade 2C)
Antiplatelet agents
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We suggest treatment with platelet concentrates if platelet dysfunction is documented in a patient with continued bleeding who has been treated with APA. (Grade 2C)
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We suggest administration of platelets in patients with ICH who have been treated with APA and will undergo surgery. (Grade 2B)
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We suggest that the administration of platelets in patients with ICH who have been treated with APA and will not undergo surgical intervention be avoided. (Grade 2B)
