Escalating regimen of haemostatic therapeutic options to treat PPH (based on recommendations of the S3-guideline 012/019 “Polytrauma/Schwerverletztenbehandlung” [Multitrauma/Treatment of Severely Injured Persons], DGAI recommendations on treating severe bleeding and ESA recommendations on treating perioperative haemorrhage) 100 ,  136 .

1.	Stabilise general conditions (prophylaxis and therapy!)	Core temperature ≥ 34 °C (preferably normothermia) pH ≥ 7.2 ionised Ca ++ concentration > 0.9 mmol/l (preferably normocalcaemia)
2.	Prevent potential (hyper-) fibrinolysis (always PRIOR to the administration of fibrinogen and/or FFP!)	Tranexamic acid (Cyklokapron ® ) initially 1 – 2 g (15 – 30 mg/kg BW), repeat as needed
3.	Substitution of oxygen carriers	RBC administration Haemostatic target in patients with severe bleeding: Hb ~ 7 – 9 g/dl (4.3 – 5.5 mmol/l) or Hct ~ 30%
4.	Substitution of clotting factors (if severe haemorrhage persists) depending on availability in hospital	FFP ≥ 20 (preferably 30) ml/kg BW or/and fibrinogen (Haemocomplettan ® ) (2–)4(–8) g (30 – 60 mg/kg BW) Target: ≥ 200 mg/dl or ≥ 2.0 g/l
	Patients who require (or are anticipated to require) massive transfusion or suffer life-threatening haemorrhagic shock may benefit from high FFP : RBC ratio of ≥1 : 2 or from combined administration of FFP and factor concentrates.	If required, PCC initially 1000 – 2500 IU (25 IU/kg BW)
		If required, 1 – 2×FXIII (Fibrogammin ® P) 1250 IU (15 – 20 IU/kg BW)
	and (if thrombocytopenia is suspected) increased platelet adhesion to endothelium + release of von Willebrand factor and FVIII from endothelium/liver sinusoids (→ agonist for vasopressin type 2 receptor)	DDAVP = desmopressin (Minirin ® ) 0.3 µg/kg BW over a period of 30 minutes (1 vial per 10 kg BW over a period of 30 min)
5.	Platelet substitution for primary haemostasis	Platelet concentrate (target for haemorrhage requiring transfusion: 100 000/µl)
6.	If necessary, thrombin burst with platelet and coagulation activation (consider general haemostatic conditions!)	In individual cases and when all other treatment options have been unsuccessful rFVIIa (NovoSeven ® ) if required, initially 90 µg/kg BW
	During ongoing bleeding	No antithrombin (ATIII) during haemorrhage , may be considered after administration of PCC and cessation of bleeding No heparin during haemorrhage
	CAUTION: Thrombosis prophylaxis is mandatory within 24 hours after cessation of the pathology causing the bleeding!