In order to simplify the initial assessment and management of a bleeding situation, we have developed the ‘haemostasis traffic light’ (Fig. 1). Firstly, we obtained our actual turnaround times over 4 months which enabled us to see which diagnostic and therapeutic resources are readily available at different time‐points during the first 45 min from the onset of bleeding 5–8. Subsequently, we developed an early clinical classification system including haemodynamic stability, requirement for and response to vasopressors and fluids, and the surgical possibility to limit bleeding over time. This aligns with the recommendation that during the initial evaluation, the physician should clinically assess the extent of the haemorrhage using a combination of patient physiology, the anatomic pattern of injury and its mechanism, along with the patient’s response to initial resuscitation manoeuvres 2. The resulting therapeutic approach we have developed targets clot stability, clot strength and thrombin generation according to the pathophysiology of the developing coagulopathy and the severity of the scenario.
When facing a red‐light situation, we suggest treating the patient immediately and drawing blood samples for viscoelastic testing to assess the initial intervention. The idea is to stop the progression of coagulopathy during severe bleeding by addressing the most frequently altered aspects of haemostasis in shock: hyperfibrinolysis, decreased clot strength and slowed thrombin generation 9. Also, when treating hemodynamic shock, one should anticipate the inevitable iatrogenic haemodilution. This is due to the aggressive volume therapy which is often needed to maintain adequate perfusion with ‘factor‐free’ fluids such as crystalloids and colloids and may interfere with thrombin generation and fibrinogen functionality. In a yellow‐light situation, the priority is to assure clot stability and strength and all further treatment should be guided by point of care measurements. Finally, in the green‐light situation, no blind interventions are needed, and a complete targeted strategy should be implemented from the start.
The triple‐colour code of a traffic light is familiar to most people and helps to prioritise diagnostic and therapeutic interventions in bleeding patients. Using an intuitive and didactic tool facilitates the process of gaining situational awareness, improves communication, raises diagnostic confidence and reduces stress and work‐load within the healthcare team 10. Another advantage of the traffic light design lies in its dynamic nature, allowing us to evaluate and re‐evaluate the clinical situation, switching into a different light if needed (‘switch and re‐assess’). One could easily argue that this proposal represents a setback in the struggle for the individualisation of medical therapies. However, we feel that the simplification of complex processes has been long‐awaited by those at the front line of bleeding and coagulation crisis management.
The haemostasis traffic light brings the possibility to narrow the gap between the bleeding experts and the bleeding caregivers at the sharp end of patient care, by providing comprehensive and pragmatic support in demanding situations. It could also serve as an educational tool during anaesthesia crisis resource management courses and formal training. Incorporating local‐specific logistical considerations, evidence‐based best‐practice treatment recommendations and human factor aspects, it aims to allow timely interventions through a standardised and optimised utilisation of both diagnostic and therapeutic resources. Finally, proper studies are needed to validate the success of this tool in the clinical setting.
1 , , , et al. Targeted coagulation management in severe trauma: the controversies and the evidence. Anesthesia and Analgesia 2016; 123: 910– 24.
2 , , , et al. The European guideline on management of major bleeding and coagulopathy following trauma: fifth edition. Critical Care 2019; 23: 98.
4 , , , , , . Human factors in preventing complications in anaesthesia: a systematic review. Anaesthesia 2018; 73( Suppl. 1): 12– 24.
Comparison of thromboelastometry (ROTEM®) with standard plasmatic coagulation testing in paediatric surgery. British Journal of Anaesthesia 2012; 108: 36– 41., , , et al.
7 , , , et al. Rotational thromboelastometry (ROTEM delta) turnaround times in a third level medical center: a cross‐sectional study in a retrospective cohort. Hematología – Sociedad Argentina de Hematología – XIII Congreso Grupo CAHT 2018; 22: 332.
8 , , , , , . Haemostasis traffic light: the development of a bleeding management tool based on turnaround times and therapeutic resources in a third level medical center. European Journal of Anaesthesiology – Euroanaesthesia 2019 Abstract Book 2019; 36: 284.
9 , , . Shock induced endotheliopathy (SHINE) in acute critical illness ‐ a unifying pathophysiologic mechanism. Critical Care 2017; 21: 25.
10 , , . The “go‐between” study: a simulation study comparing the “Traffic Lights” and “SBAR” tools as a means of communication between anaesthetic staff. Anaesthesia 2016; 71: 764– 72.