The article by Franke et al. (1) recommends wound packing or tamponade to stop bleeding; that this should be combined with the administration of a hemostyptic is only stated in parentheses. Unfortunately, the hemostyptics are not further defined.

The recommended treatment for dealing with massive bleeding and associated perioperative coagulation disorders is described in Grottke et al. (2). As transfusion triggers are often not immediately available, pragmatic rapid therapy should be used (3). For blood loss of approximately 5 liters, approximately 10 units of red blood cell concentrates of the blood group 0 (if the patient has an unknown blood group) should be transfused, together with 4 to 5 units of platelet concentrates of any blood group.

The required volume therapy should be essentially carried out with crystalloid solutions if fresh plasma is not sufficiently available in liquid form, and otherwise, in combination with fresh plasma (using 2 to 3 liters of either crystalloid solution or fresh plasma of blood group AB).

Once a patient has lost 5 liters of blood, the coagulation activity is only about 30% active. Therefore, 4000 IU of the coagulation factors II, VII, IX, and X (prothrombin complex concentrate, PCC) should be co-administered if only the crystalloid and colloidal solution is used, and about 2000 IU of PCC if fresh plasma is used. For massive bleeding, activated PCC should be used. However, 4 g of fibrinogen should be given intravenously in parallel so that sufficient fibrin is available for blood clotting.

Positive experiences have been reported for treating dilutional coagulopathy due to large blood loss with recombinant factor VIIa (for example, administering 7 mg for an 80 kg patient) (4). This factor can be used in addition to volume therapy and administration of non-activated PCC.

Once the bleeding has been stopped, it is imperative to administer heparin for anticoagulation, due to the high risk of thrombosis, until complete mobilization is achieved.

DOI: 10.3238/arztebl.2017.0562a

Prof. Dr. med. Dr. -Ing. Holger Kiesewetter

Hämostaseologicum

Berliner Zentrum für Blutgerinnungserkrankungen, Germany

2.haemo-mitte@haemostaseologicum-steglitz.de

1.
Franke A, Bieler D, Friemert B, Schwab R, Kollig E, Güsgen C: The first aid and hospital treatment of gunshot and blast injuries. Dtsch Arztebl Int 2017; 114: 237–43 VOLLTEXT
2.
Grottke O, Frietsch T, Maas M, et al.: Handlungsempfehlung, Umgang mit Massivblutungen und assoziierten perioperativen Gerinnungsstörungen. Anästh Intensivmed 2013; 54: 147–57.
3.
Henrich W, Surbek D, Kainer F, et al.: Diagnosis and treatment of peripartum bleeding. Perinat Med 2008; 36: 467–78 CrossRef MEDLINE
4.
Hauser CJ, Boffard K, Dutton A, et al.: Results of the CONTROL trial: efficacy and safety of recombinant activated Factor VII in the management of refractory traumatic hemorrhage. J Trauma 2010; 69: 489–500 CrossRef MEDLINE
1. Franke A, Bieler D, Friemert B, Schwab R, Kollig E, Güsgen C: The first aid and hospital treatment of gunshot and blast injuries. Dtsch Arztebl Int 2017; 114: 237–43 VOLLTEXT
2.Grottke O, Frietsch T, Maas M, et al.: Handlungsempfehlung, Umgang mit Massivblutungen und assoziierten perioperativen Gerinnungsstörungen. Anästh Intensivmed 2013; 54: 147–57.
3. Henrich W, Surbek D, Kainer F, et al.: Diagnosis and treatment of peripartum bleeding. Perinat Med 2008; 36: 467–78 CrossRef MEDLINE
4. Hauser CJ, Boffard K, Dutton A, et al.: Results of the CONTROL trial: efficacy and safety of recombinant activated Factor VII in the management of refractory traumatic hemorrhage. J Trauma 2010; 69: 489–500 CrossRef MEDLINE

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