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The current S2k guidelines on the diagnostics and treatment of peripartum hemorrhage are summarized in this article from the perspective of anesthesiology based on a fictitious case report. The update of the guidelines was written under the auspices of the German Society of Gynecology and Obstetrics with the participation of other professional societies and interest groups from Germany, Austria and Switzerland and published by the AWMF in 2022 under the register number 015/063.

Research shows that people boost effort to obtain rewards. When determining which rewards to pursue, people analyze the expected values of these rewards. Previous research has shown that by doing these analyses frequently, it can become an automatized process where initial cues can boost performance outside of awareness, via unconscious processes. However, there have been a lot of critiques on the way that awareness has been measured in previous research. These critiques depend on fundamental methodological problems within the classic method of signal detection. In this study, we want to exclude the issue of people being aware or not by creating an experiment on trial level where people can earn a monetary reward depending on their performance. Next to the conscious (optimal) and unconscious (suboptimal) trial, we added a baseline trial where people were not exposed to a monetary reward. We focus on the response times of the ‘SL/OH’ suboptimal trials compared to the ‘SL/OX’ baseline trial, and therefore ruling out the possibility of people being aware of the monetary reward. Although we replicated previous measure methods and it made us find the classic effect of reward priming on behavior initially, when using a sufficient detection and comparing the ‘SL/OH’ suboptimal trials with the ‘SL/OX’ baseline trials there has not been found an effect of reward priming on behavior. Results indicated that priming had no effect on the response times compared to the baseline trial, meaning that a direct effect of reward primes on behavior has not been found.

The use of tranexamic acid (TXA), an antifibrinolytic drug, has received increasing attention in the coagulation management of severely injured patients. Based on the results of the prospective, multicenter Clinical Randomization of an Antifibrinolytic in Significant Hemorrhage-2 (CRASH-2) study with 20,211 patients, European experts were fairly quick to give high grading recommendations for TXA. However, the transferability of these results to modern trauma systems remains questionable and is doubted by some studies. Growing knowledge of trauma-induced coagulopathy with different phenotypes also impedes the universal application of TXA for all trauma patients. TXA is a medication; therefore, it requires an indication and has effects but also side effects. Especially in severely injured patients, TXA's current target population, some recent publications find a decreased mortality but increased thromboembolic effects. Only after evaluation of the results of current trials are evidence-based recommendations for prehospital application of TXA possible.

Traumatic brain injury and massive bleeding are the most frequent causes of death in severely injured patients. Uncontrolled hemorrhage is still a major cause of preventable death after trauma. The current German S3 trauma guideline on the treatment of polytrauma and severely injured patients emphasize the importance of early bleeding control in various areas. Besides uncontrolled hemorrhage, subsequent trauma-induced coagulopathy (TIC) is a second frequent problem after trauma; therefore, the current guideline addresses TIC in a separate and dedicated chapter. The key factors in management of TIC are early detection and aggressive therapy. Apart from standard coagulation tests and parameters indicating shock, viscoelastic tests are of increasing interest in the diagnostics of TIC. Trauma centers are urged to establish massive transfusion and coagulation protocols, which are individually adapted to the structure of the hospital. For treatment an optimization of the preconditions of coagulation, such as normothermia, normovolemia, normocalcemia and prevention of acidosis must be considered, even if sometimes hard to establish. Besides damage control resuscitation, two therapeutic approaches are possible: a ratio-driven and a coagulation factor-based regimen for treatment of TIC. Independent of the preferred concept, the early use of tranexamic acid should be taken into consideration for bleeding trauma patients. The present article summarizes the coagulation chapter of the current German guideline and gives a brief overview of current publications on this topic.

In 2011 the first interdisciplinary S3 guideline for the management of patients with serious injuries/trauma was published. After intensive revision and in consensus with 20 different medical societies, the updated version of the guideline was published in 2016. Divided into the three different sections prehospital care, emergency room management, and first operative phase, many recommendations and explanations were updated, mostly in the prehospital care and emergency room management sections. The prehospital care section is of special interest for all members of emergency medical services (e.g., emergency physician, paramedics, emergency technicians). The present work summarizes changes and innovations in prehospital care of the current guideline in a practice-oriented manner using the ABCDE scheme.

The term shock refers to a life-threatening circulatory failure caused by an imbalance between the supply and demand of cellular oxygen. Hypovolemic shock is characterized by a reduction of intravascular volume and a subsequent reduction in preload. The body compensates the loss of volume by increasing the stroke volume, heart frequency, oxygen extraction rate, and later by an increased concentration of 2,3-diphosphoglycerate with a rightward shift of the oxygen dissociation curve. Hypovolemic hemorrhagic shock impairs the macrocirculation and microcirculation and therefore affects many organ systems (e.g. kidneys, endocrine system and endothelium). For further identification of a state of shock caused by bleeding, vital functions, coagulation tests and hematopoietic procedures are implemented. Every hospital should be in possession of a specific protocol for massive transfusions. The differentiated systemic treatment of bleeding consists of maintenance of an adequate homeostasis and the administration of blood products and coagulation factors.