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Blizard Institute - Faculty of Medicine and Dentistry

Focused, rapid interventions for injured patients with major bleeding saves thousands of lives

Trauma helicopter

Professor Karim Brohi and his colleagues have developed new treatment approaches for trauma patients with critical bleeding that have reduced death rates by nearly 30% percent at the Royal London Hospital, one of the busiest major trauma centres in Europe. The damage control resuscitation (DCR) strategy and major haemorrhage protocol (MHP, or ‘Code Red’) were adopted as national standards by the NHS in 2016.

Speedy intervention is vital

Trauma is a major cause of death and disability worldwide. 

This disproportionately affects the young. 90,000 people under 30 die from injuries every year in Europe, and half of these deaths are due to bleeding. The mortality rates for trauma patients with massive haemorrhage is over 50%. One of the main reasons for this high rate of death is abnormal blood clotting after injury. 

The importance of coagulation

When an injured patient is losing a great deal of blood, their clotting system stops working correctly.

Loss of clotting function (coagulopathy) in severe bleeding was originally thought to be a late phenomenon caused by the loss or dilution of blood coagulation factors. Professor Brohi analysed blood samples from trauma patients brought by the Helicopter Emergency Medical Service to the Royal London Hospital. He was able to identify that one in four patients already had established coagulopathy on arrival — and that this ‘Acute Traumatic Coagulopathy’ (ATC) meant that they were four times more likely to die. 

Professor Brohi’s team, showed that in trauma patients’ blood, clots form slowly, are weaker than normal, and are broken down quickly. They have introduced new blood clotting blood tests that can be performed in the emergency department or operating theatre, have evaluated new pharmaceutical and blood-derived clotting treatments, and developed a new approach to resuscitation of these patients “Damage Control Resuscitation”.

This work has been supported by the NIHR, European Commission and Barts Charity. Damage Control Resuscitation is now the accepted standard approach for bleeding trauma patients nationally (adopted by NICE in 2016) and worldwide.

How have these discoveries changed trauma treatment?

Queen Mary’s DCR strategy and MHP have been adopted or recommended both nationally and internationally. As a result, Queen Mary’s trauma team has:

Drastically reduced deaths  

  • Mortality rates from bleeding were reduced by 29.4% between 2014 and 2020 at the Royal London Hospital
  • The average number of red blood cell transfusions required by each patient in the first 24 hours also dropped from 12 to just 4
  • The number of patients who needed a massive transfusion (10 or more units, essentially replacing their entire blood volume) dropped by more than half

Influenced national and international clinical guidelines  

The UK’s National Institute for Health and Care Excellence (NICE) for Major Trauma now recommends that all ambulance trusts and trauma units have: 

  • a specific major haemorrhage protocol for adults and children
  • a fixed-ratio protocol for blood components (blood and plasma) to prevent coagulopathy worsening
  • early use of tranexamic acid to stop clots breaking down

This coagulation-centric approach has also been incorporated into: 

  • UK national transfusion guidelines for all major bleeding 
  • European guidelines on the management of trauma haemorrhage 
  • The global Advanced Trauma Life Support Manual 
  • The international Viscoelastic Testing in Trauma Consensus Panel
  • Guidelines from the British Society for Haematology 

A change in the management of trauma

DCR was adopted by the NHS Commissioning Board (now NHS England) in April 2014. It is now the primary resuscitation and clinical management strategy for patients suffering from major traumatic bleeding. 

Over 11,000 severely injured patients per year are admitted to trauma centres in the UK. Around ten per cent of these patients are treated using the MHP. MHP, or ‘Code Red’, has been adopted as an essential criterion for the accreditation of all major trauma centres in England.

The introduction of major haemorrhage protocols is estimated to save the NHS GBP6,600,000 a year, with wider social cost savings estimated over a five-year period being GBP3,600,000,000 (in 2010 prices).