# Prehospital 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 before hospital arrival, based on recent evidence and expert consensus.

## Contribution

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

## Key findings

- Thirty-five new studies were analyzed to update prehospital fluid and coagulation management guidelines.
- Four existing recommendations were modified, and six new ones were added based on strong expert consensus.
- Key recommendations include fluid restriction in uncontrolled bleeding and addressing the lethal triad at the prehospital stage.

## Abstract

Our aim was to update the evidence-based and consensus-based recommendations for prehospital 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 fluid replacement therapy, the transfusion of blood products, the management of coagulation, or intravenous/intraosseous access in patients with multiple and/or severe injuries in the prehospital 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.

Thirty-five new studies were identified. Interventions covered were prehospital fluid replacement therapy (n = 5 studies), infusions (n = 3), transfusions (n = 11), coagulation management (n = 13), and intraosseous access (n = 2). Four recommendations were modified, and six additional recommendations were developed. All achieved strong consensus.

The following key recommendations are made. Fluid replacement therapy should be initiated in severely injured patients. In patients with uncontrolled bleeding, fluid replacement therapy should be limited (MAP of 65 mmHg, SBP of 80 mmHg) in order to maintain minimum haemodynamic stability while not increasing blood loss. In hypotensive patients with suspected isolated or concomitant significant traumatic brain injury, the objective of fluid replacement should be to maintain normal blood pressure (MAP of 85 mmHg, SBP of 110 mmHg). Intravenous access is used in trauma patients. If intravenous access cannot be achieved in trauma patients, intraosseous access is used for the delivery of fluids and medications. If there are no signs and symptoms of volume depletion, fluid replacement therapy should not be provided. If the administration of a sufficient volume of fluids fails to achieve adequate blood pressure in a polytrauma patient, the titrated use of vasopressors for circulatory support may be considered. The lethal triad of hypothermia, acidosis, and coagulopathy should be addressed at the prehospital stage. One gram of tranexamic acid should be administered in cases of existing or imminent haemorrhagic shock. The administration of fibrinogen may also be considered in cases of uncontrollable bleeding, as may the administration of erythrocyte and plasma concentrates.

The online version contains supplementary material available at 10.1007/s00068-025-02984-7.