# Inhospital coagulation management and fluid replacement therapy in patients with multiple and/or severe injuries – a systematic review and clinical practice guideline update

## TL;DR

This paper updates clinical guidelines for managing coagulation and fluid therapy in severely injured patients, emphasizing targeted treatments based on evidence.

## Contribution

The study provides updated, evidence-based recommendations for coagulation management and fluid replacement in trauma patients.

## Key findings

- Viscoelastic assays are recommended for diagnosing and treating trauma-induced coagulopathy.
- Tranexamic acid should not be used indiscriminately due to limited benefit in non-hyperfibrinolytic patients.
- Coagulation factor concentrates and TXA are indicated for life-threatening hemorrhage.

## Abstract

Our aim was to update the evidence-based and consensus-based recommendations for inhospital coagulation management and fluid replacement therapy in patients with multiple and/or severe injuries on the basis of current evidence. This guideline topic is part of the 2022 update of the German Guideline on the Treatment of Patients with Multiple and/or Severe Injuries.

MEDLINE and Embase were systematically searched to May 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 the prevention of acidaemia, hypocalcaemia and hypothermia, for coagulation management, fluid replacement therapy, blood product transfusions, viscoelastic assays, or central venous access in patients with multiple and/or severe injuries in the hospital setting. We considered patient-relevant clinical outcomes, such as mortality and bleeding control, or coagulation parameters as 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.

Fifty-nine new studies were identified. Interventions covered were blood products (n = 19 studies), coagulation management (n = 14), viscoelastic assays (n = 12), temperature management (n = 5), fluid replacement therapy (n = 4), base excess/lactate (n = 3), calcium (n = 1), and intravenous access (n = 1). Twelve recommendations were modified, and seven additional recommendations were developed. All achieved strong consensus.

The key recommendations are summarised as follows.

Trauma-induced coagulopathy (TIC) is a distinct clinical entity requiring early diagnostic and therapeutic interventions.Perform viscoelastic assays in order to aid in the diagnosis and treatment of TIC in severely bleeding trauma patients.Since only approximately 20% of trauma patients are hyperfibrinolytic and tranexamic acid is not beneficial in the absence of hyperfibrinolysis, TXA should not be indiscriminately used in all patients in the emergency department.Coagulation factor concentrates as well as TXA are indicated in patients with life-threatening haemorrhage and/or haemorrhagic shock.

Trauma-induced coagulopathy (TIC) is a distinct clinical entity requiring early diagnostic and therapeutic interventions.

Perform viscoelastic assays in order to aid in the diagnosis and treatment of TIC in severely bleeding trauma patients.

Since only approximately 20% of trauma patients are hyperfibrinolytic and tranexamic acid is not beneficial in the absence of hyperfibrinolysis, TXA should not be indiscriminately used in all patients in the emergency department.

Coagulation factor concentrates as well as TXA are indicated in patients with life-threatening haemorrhage and/or haemorrhagic shock.

The online version contains supplementary material available at 10.1007/s00068-025-02919-2.