Search Results (8)

Background and Objectives: Traumatic hemorrhage remains the leading cause of preventable death following major injury, with most hemorrhage-related fatalities occurring within the first hours after trauma. During this early phase, trauma-induced coagulopathy (TIC) frequently develops as an independent pathophysiological response, affecting up to one-third of severely injured patients and being strongly associated with increased morbidity and mortality. Over the past two decades, TIC has been recognized as a complex endogenous process rather than a simple consequence of dilution, hypothermia, or acidosis, prompting a paradigm shift in early trauma resuscitation. Materials and Methods: This narrative review analyzes the current literature on the pathophysiology of TIC and the evolution of hemostatic resuscitation strategies. Key topics include the mechanisms underlying early coagulopathy, its clinical impact, and the evidence supporting contemporary therapeutic approaches. Published data on balanced transfusion strategies, whole blood transfusion, fibrinogen replacement, cryoprecipitate, prothrombin complex concentrates, tranexamic acid and viscoelastic-guided resuscitation were reviewed, along with relevant international guidelines. Results: Emerging evidence supports early, balanced, and targeted hemostatic resuscitation to mitigate the effects of TIC and improve outcomes in bleeding trauma patients. Balanced transfusion ratios, prompt correction of fibrinogen deficiency, early antifibrinolytic therapy and selective use of coagulation factor concentrates have been associated with reduced transfusion requirements and improved survival. Viscoelastic testing enables rapid, individualized assessment of coagulation abnormalities, although its availability and implementation remain inconsistent across trauma systems. Conclusions: Early recognition and aggressive, structured management of trauma-induced coagulopathy are essential to reduce preventable deaths from traumatic hemorrhage. While advances in hemostatic resuscitation have improved outcomes, significant challenges remain in standardizing treatment protocols and expanding access to viscoelastic diagnostics. Ongoing research and system-level optimization are needed to further refine and disseminate evidence-based strategies for the management of TIC. Full article

Background: Venous thromboembolism (VTE) remains a clinically relevant complication following major orthopaedic procedures, particularly total hip arthroplasty (THA), total knee arthroplasty (TKA), and fracture surgery. Although low-molecular-weight heparin (LMWH) and direct oral anticoagulants (DOACs) are widely regarded as standard pharmacological options, aspirin (acetylsalicylic acid, ASA) has gained renewed attention because of its low cost, oral administration, and favourable bleeding profile. However, the available evidence is heterogeneous, and its interpretation is complicated by differences in patient selection, timing and duration of prophylaxis, diagnostic methodology, aspirin dosing regimens, and the increasing adoption of modern fast-track arthroplasty pathways. Methods: A structured evidence-based review was conducted in accordance with PRISMA 2020 principles. PubMed, Embase, Web of Science, and the Cochrane Library were searched through September 2025 for randomised controlled trials (RCTs), major international clinical practice guidelines, and selected high-level studies relevant to the interpretation of aspirin-based orthopaedic thromboprophylaxis. Nine RCTs, four major guideline documents, and sixteen additional Level I–II studies were included. Outcomes of interest were symptomatic deep vein thrombosis (DVT), pulmonary embolism (PE), major bleeding, and mortality. Risk of bias was assessed using the Cochrane ROB 2 framework. Owing to marked methodological heterogeneity, no formal pooled meta-analysis was undertaken. Results: The available RCT evidence suggests that aspirin may perform adequately within structured sequential or risk-stratified prophylaxis strategies, but not in all clinical settings. In arthroplasty, EPCAT II demonstrated non-inferiority of aspirin when introduced after an initial five-day course of rivaroxaban, whereas CRISTAL showed higher early symptomatic VTE rates when aspirin was used as sole primary prophylaxis from postoperative day 0. Importantly, thromboembolic events in CRISTAL occurred earlier in the aspirin cohort, supporting the concept that anticoagulant therapy remains important during the immediate postoperative hypercoagulable phase. In trauma surgery, PREVENT CLOT established non-inferiority of aspirin compared with LMWH for 90-day mortality; however, the predominantly young study population and the inclusion of upper-extremity fractures limit extrapolation to elderly hip fracture patients. Several smaller RCTs reported no major differences between aspirin and anticoagulants, but these studies were frequently underpowered and relied on less sensitive diagnostic strategies. Historical and contemporary guidelines remain heterogeneous, and evidence from modern fast-track arthroplasty pathways suggests that current trial-based conclusions may not be directly generalisable to short-duration prophylaxis settings. Conclusions: Aspirin may have a role in orthopaedic thromboprophylaxis when used within structured, risk-adapted or sequential protocols, particularly in standard-risk arthroplasty patients and selected trauma populations. However, current evidence does not support its universal use as sole primary prophylaxis in major orthopaedic surgery, especially during the early postoperative hypercoagulable phase or in high-risk patients. Furthermore, the available literature does not permit definitive recommendations regarding the optimal aspirin dose or duration of prophylaxis. The generalisability of the existing literature is further limited by methodological heterogeneity and by the absence of RCTs directly evaluating ultra-short anticoagulant regimens versus prolonged aspirin prophylaxis in modern fast-track arthroplasty. Further high-quality, standardised trials are required. Full article

Introduction. Pediatric polytrauma (PPT) and major trauma in pediatric patients (PMT) present unique challenges compared to adult trauma care due to distinct anatomical and physiological differences. PPT/PMT remains the leading cause of death in children, responsible for over 50% of pediatric deaths and 15% of pediatric hospital admissions due to its long-term effects. This single-institution study focuses on the initial management of PPT/PMT from an orthopedics and traumatology point of view. Material and Methods. In the present study, data of PPT/PMT managed in one single institution, an academic level I pediatric trauma center, in patients <18 years of age, were analyzed over different periods. Over a 10-year period, diaphyseal femur fractures were analyzed as indicators of damage control (DCO) versus definitive treatment. Over a 4-year period (2021–2024), the associated lesions of PPT (head injuries, thoracic and abdominal lesions, spine lesions, major blood vessel lesions, and major musculoskeletal injury) were analyzed. Over a 1-year period (2019), the overall in-hospital mortality and admission rates in the pediatric intensive care unit were analyzed. Results. In the 10-year period, among 298 diaphyseal femur fractures, 46/298 (15%) were classified as PPT in which DCO was performed according to age as follows: in the age-group 15–17 years 23/23 (100%) with temporary external fixation (ExFix); in the age group 12–14 years, 9/14 (64%) with ExFix and 5/14 (26%) and elastic stable intramedullary nails (ESINs); in the age group 5–11 years, 1/5 (20%) with ExFix and 4 with ESIN; in the age group 0–4 years, 2/4 (50%) with ESIN and 2/4 (50%) with a cast. In the 4-year period, PPT/PMTs were associated with 60% head injury, 25% thoracic lesion(s), 18% abdominal lesion(s), 16% spine injury, 5% lesion of a major blood vessel, and 30% major musculoskeletal injuries. In 2019, there were 193 patients admitted to the emergency room as PPT/PMT: 115 were ≤12 years old and 78 were >12 years old. On admission, 46% were admitted to the pediatric intensive care unit, and 65% were admitted to the department of traumatology as inpatients. The in-hospital mortality rate was 7%. Discussion and Conclusions. In our institution, pediatric trauma is assessed using the Pediatric Trauma Score (PTS), and the workup follows the ATLS guidelines with a dedicated trauma team. The role of the orthopedic surgeon during the primary evaluation of PPT/PMT is to contribute to stopping bleeding and hemorrhagic shock. In PPT/PMT, DCO in adolescents is superimposable to adults, whilst in babies and children, DCO is still performed, but it is not a form of temporary external fixation. Full article

Background: The increasing incidence of pelvic ring and acetabular fractures represents a major challenge in the field of trauma surgery. Hemorrhage and thrombosis are among the most severe complications associated with these injuries. The common instability of those fractures, together with an anatomic proximity to blood vessels, increases the risk of perioperative bleeding. Vascular wall irritation during surgery additionally adds to a substantial risk for thrombotic events. Therefore, evaluating the risk for hemorrhage and thrombosis in pelvic ring and acetabular fractures is vital to identify an adequate anticoagulation management. Methods: The incidence of hemorrhagic and thrombotic events, as well as the association of patient characteristics with the investigated outcomes of 16,359 cases, were analyzed retrospectively using data from the German Pelvic Trauma Registry. Moreover, a risk assessment survey was conducted among traumatologists experienced in pelvic ring and acetabular surgery. The results were compared to those of the registry study. Results: A high rate of thrombotic events was found in the middle-age decade (41–50 years). In patients with an age ≤ 40 and >50 years, hemorrhage complications predominated. The logistic regression identified pelvic ring fractures in geriatric patients, acetabular fractures, and Injury Severity Score (ISS) ≥ 16 to be associated with bleeding complications. Factors associated with thrombosis included pelvic ring fractures in non-geriatric patients, acetabular fractures in geriatric and non-geriatric patients, ISS, and male gender. The survey demonstrated that preoperatively, the risk for hemorrhage was considered more significant. Perioperatively, however, thrombosis was regarded as more important. Conclusions: Separate guidelines for prophylactic anticoagulation in pelvic ring and acetabular fractures that also consider individual patient characteristics, such as age, gender, and ISS, are necessary to improve perioperative management and reduce the morbidity and mortality associated with these injuries. Full article

Background: Trauma is a major global public health concern. Many countries are working to reduce preventable deaths; however, the mortality rate remains higher than their goal, indicating a need for continuous development in trauma care, including further improvements across the system. This article explores recent developments and updated guidelines for both prehospital emergency care and in-hospital trauma management, emphasizing evidence-based and patient-centered approaches. Current concepts: In the prehospital phase, the primary focus is on early and aggressive hemorrhage control using techniques such as tourniquet application, wound packing, and permissive hypotension as standard practices. Advancements in this field, including intraosseous vascular access and tranexamic acid administration, have improved patient outcomes. The emphasis on structured assessments, particularly “circulation, airway, breathing” (CAB) assessments, underscores the importance of managing life-threatening hemorrhages. During the in-hospital phase, the primary focus is on controlling bleeding. Protocols emphasize the judicious administration of fluids to prevent over-resuscitation and mitigate the risk of exacerbating coagulopathy. Efficient transfusion strategies are implemented to address hypovolemia, while ensuring balanced ratios of blood products. Furthermore, the implementation of advanced interfacility transfer systems and communication tools such as “Situation, Background, Assessment, Recommendation” (SBAR) plays a pivotal role in optimizing patient care and reducing delays in definitive treatment. Discussion and Conclusions: This review highlights the importance of implementing advanced strategies to align with international standards and further decrease the rate of preventable trauma-related deaths. Strengthening education and optimizing resource allocation for both prehospital and hospital-based trauma care are essential steps toward achieving these objectives. Full article

Background and Objectives: Trauma, particularly uncontrolled bleeding, is a major cause of death. Recent evidence-based guidelines recommend the use of a tourniquet when life-threating limb bleeding cannot be controlled with direct pressure. Prehospital hemorrhage management, according to the XABCDE protocol, emphasizes the critical role of tourniquets in controlling massive bleeding. The aim of this systematic review and meta-analysis was to summarize data from the available scientific literature on the effectiveness of prehospital tourniquet use for extremity bleeding. Materials and Methods: A systematic review and meta-analysis was performed between March 2022 and March 2024, adhering to PRISMA guidelines, to determine whether prehospital tourniquets are clinically effective. The protocol was published on PROSPERO (ID number: CRD42023450373). Results: A comprehensive literature search yielded 925 articles and 11 studies meeting the inclusion criteria. The analysis showed a non-statistically significant reduction in mortality risk with tourniquet application (4.02% vs. 6.43%, RR 0.70, 95% CI 0.46–1.07). Analysis of outcomes of amputation of the traumatized limb indicated a statistically higher incidence of initial amputation in the tourniquet group (19.32% vs. 6.4%, RR 2.07, 95% CI 1.21–3.52), while delayed amputation showed no difference (9.39% vs. 3.66%, RR 0.93, 95% CI 0.42–2.07). Tourniquet use demonstrated a non-significant reduction in the number of blood components transfused (MD = −0.65; 95% CI −5.23 to 3.93 for pRBC, MD = −0.55; 95% CI −4.06 to 2.97 for plasma). Conclusions: Despite increasing use in civilian settings, this systematic review and meta-analysis showed no significant reduction in mortality or blood product use associated with prehospital tourniquet use. Further research, including high-quality randomized controlled trials, is required, as well as awareness and education campaigns relating to proper tourniquet use in the prehospital setting. Full article

Early recognition of coagulopathy is necessary for its prompt correction and successful management. Novel approaches, such as point-of-care testing (POC) and administration of coagulation factor concentrates (CFCs), aim to tailor the haemostatic therapy to each patient and thus reduce the risks of over- or under-transfusion. CFCs are an effective alternative to ratio-based transfusion therapies for the correction of different types of coagulopathies. In case of major bleeding or urgent surgery in patients treated with vitamin K antagonist anticoagulants, prothrombin complex concentrate (PCC) can effectively reverse the effects of the anticoagulant drug. Evidence for PCC effectiveness in the treatment of direct oral anticoagulants-associated bleeding is also increasing and PCC is recommended in guidelines as an alternative to specific reversal agents. In trauma-induced coagulopathy, fibrinogen concentrate is the preferred first-line treatment for hypofibrinogenaemia. Goal-directed coagulation management algorithms based on POC results provide guidance on how to adjust the treatment to the needs of the patient. When POC is not available, concentrate-based management can be guided by other parameters, such as blood gas analysis, thus providing an important alternative. Overall, tailored haemostatic therapies offer a more targeted approach to increase the concentration of coagulation factors in bleeding patients than traditional transfusion protocols. Full article

Non-controlled hemorrhage with accompanying trauma-induced coagulopathy (TIC) remains the most common cause of preventable death after multiple injury. Rapid identification followed by aggressive treatment is the key for improved outcomes. Treatment of trauma hemorrhage begins at the scene, with manual compression, the use of tourniquets and (non) commercial pelvic slings, and rapid transfer to an adequate trauma center. Upon hospital admission, coagulation monitoring and support are to be initiated immediately. Bleeding is controlled surgically following damage control principles. Modern coagulation management includes goal-oriented, individualized therapies, guided by point-of-care viscoelastic assays. Idarucizumab can be used as an antidote to the thrombin inhibitor dabigatran, andexanet alpha as an antidote to factor Xa inhibitors. This review summarizes the key recommendations of the 2019 updated European guideline on the management of major bleeding and coagulopathy following trauma. These evidence-based recommendations may form the backbone of algorithms adapted to local logistics and infrastructure. Full article