Trauma bleeding management: the concept of goal-directed primary care

The early and aggressive high-volume administration of fresh frozen plasma, platelet concentrates, and red blood cells (RBCs), using ratio-driven massive transfusion protocols, has been adopted by many for the treatment of trauma-induced coagulopathy and hemorrhagic shock. However, the optimal ratio of RBC: fresh frozen plasma and RBC:platelet concentrate is still under investigation. In some European trauma centers, hemostatic agents such as fibrinogen concentrate, prothrombin complex concentrates, and antifibrinolytics are integral parts of goal-directed massive transfusion protocols. Both a ratio-driven coagulation therapy and a point-of-care-guided coagulation management based on coagulation factor concentrates aim for the same target-the rapid prevention and treatment of shock and coagulopathy to prevent death from traumatic hemorrhage. In this review, we compare the evidence relating to the effectiveness and safety of the ratio-driven and goal-directed approaches to trauma-induced coagulopathy to draw attention to the potential benefits and drawbacks associated with these management strategies.