The guideline development group participated in a web conference in March 2009 to define the scientific questions to be addressed in the guideline. Selection, screening and grading of the literature and formulation of recommendations were accomplished Dorsomorphin solubility in subcommittee groups consisting of at least three members via electronic or telephone communication. After distribution of the recommendations to the entire group, a face-to-face meeting of the task force was held in June 2009 with the aim of reaching a consensus on the draft recommendations from each subcommittee. After final refinement of the rationale for each recommendation and the complete manuscript, the updated document was approved by the endorsing organisations between October 2009 and January 2010. An updated version of the guideline is anticipated in due time.

In the GRADE system for assessing each recommendation, the letter attached to the grade of recommendation reflects the degree of literature support for the recommendation, whereas the number indicates the level of support for the recommendation assigned by the committee of experts. Recommendations are grouped by category and somewhat chronologically in the treatment decision-making process, but not by priority or hierarchy.ResultsI. Initial resuscitation and prevention of further bleedingMinimal elapsed timeRecommendation 1 We recommend that the time elapsed between injury and operation be minimised for patients in need of urgent surgical bleeding control (Grade 1A).

Rationale Trauma patients in need of emergency surgery for ongoing haemorrhage have increased survival if the elapsed time between the traumatic injury and admission to the operating theatre is minimised. More than 50% of all trauma patients with a fatal outcome die within 24 hours of injury [2]. Despite a lack of evidence from prospective RCTs, well-designed retrospective studies provide evidence for early surgical intervention in patients with traumatic haemorrhagic shock [21-23].In addition, studies that analyse trauma systems indirectly emphasise the importance of minimising the time between admission and surgical bleeding control in patients with traumatic haemorrhagic shock [24,25]. At present, the evidence base for the impact of the implementation of the Advanced Trauma Life Support (ATLS) protocol on patient outcome is very poor, because the available literature focuses primarily on the effectiveness of ATLS as an educational tool [26].

Future studies are needed to define the impact of the ATLS program within trauma systems at the hospital and health system level in terms of controlled before-and-after implementation designed to assess post-injury mortality as the primary outcome parameter.Tourniquet useRecommendation 2 We recommend Carfilzomib adjunct tourniquet use to stop life-threatening bleeding from open extremity injuries in the pre-surgical setting (Grade 1C).