Ewoud ter Avest

Acute medicine is characterized by its unpredictable nature. In contrast to other clinical research settings, it is usually not possible to identify candidates for research prior to the event that triggers the inclusion of the participant in a clinical study. Patients may be severely ill, have an impaired level of consciousness or delirium, which can affect their ability to provide informed consent. Strictly relying on informed consent by the patient may result in participation bias [1-4].

We thank Mathais et al. [1] and O'Sullivan et al. [2] for their constructive comments on our study [3]. Rapid access to definitive haemorrhage control is paramount. However, in patients in profound haemorrhagic shock or at imminent risk of traumatic cardiac arrest, obtaining large-bore intravenous access to enable effective blood resuscitation can be the single most important pre-hospital intervention, as it may prevent cardiac arrest before haemorrhage control is achieved.

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