Trauma-induced coagulopathy management

Authors

  • Maria Grazia Bocci Scienze dell’emergenza, anestesiologiche e della rianimazione, UOC Anestesia, Rianimazione, Terapia Intensiva e Tossicologia Clinica, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma - Italy https://orcid.org/0000-0001-6100-8442

DOI:

https://doi.org/10.33393/ao.2022.2425

Keywords:

Coagulation, Hemorrhage, Hemorrhagic shock, Practice guidelines, Trauma-induced coagulopathy

Abstract

In the last years significant progress has been made in the understanding and treatment of hemorrhage caused by trauma which (along with the advances made in early resuscitation, and critical care) has led to a reduction of “late” deaths, meaning those due to trauma-induced organ failure/sepsis. Depending on the case, trauma is usually characterized by a variable equilibrium between hypo and hypercoagulation, with a majority of hypercoagulation cases. Trauma-induced coagulopathy (TIC), instead, is not only characterized by a coagulation disorder but also a state of inflammation which increases the need for transfusions, the risk of multiorgan failure and thromboembolic complications. In this clinical picture, hemostatic resuscitation, damage control resuscitation and homeostasis maintenance have been shown to reduce mortality. According to guidelines, the heart of TIC treatment is an early individualised goal-directed treatment relying on coagulation support and thromboprophylactic strategies (administration of tranexamic acid, fibrinogen concentrate and packed red blood cells), platelet function monitoring and viscoelastic Point-of-care testing. The implementation of the protocol suggested by the guidelines has allowed a more effective support of coagulopathy and has led to a reduction in hemoderivatives usage, hospitalization time and the death rate in severely injured trauma patients. The aforementioned improvements in TIC management were explicitly confirmed by a multicentric study in which the year the guidelines were implemented was compared with a prior year when no specific protocol was executed.

References

Gunst M, Ghaemmaghami V, Gruszecki A, Urban J, Frankel H, Shafi S. Changing epidemiology of trauma deaths leads to a bimodal distribution. Proc Bayl Univ Med Cent. 2010;23(4):349-354. https://doi.org/10.1080/08998280.2010.11928649 PMID:20944754

Kauvar DS, Lefering R, Wade CE. Impact of hemorrhage on trauma outcome: an overview of epidemiology, clinical presentations, and therapeutic considerations. J Trauma. 2006;60(6)(suppl):S3-S11. https://doi.org/10.1097/01.ta.0000199961.02677.19 PMID:16763478

Savioli G, Ceresa IF, Caneva L, Gerosa S, Ricevuti G. Trauma-Induced Coagulopathy: Overview of an Emerging Medical Problem from Pathophysiology to Outcomes. Medicines (Basel). 2021;8(4):16. https://doi.org/10.3390/medicines8040016 PMID:33805197

Brohi K, Cohen MJ, Davenport RA. Acute coagulopathy of trauma: mechanism, identification and effect. Curr Opin Crit Care. 2007;13(6):680-685. https://doi.org/10.1097/MCC.0b013e3282f1e78f PMID:17975390

Brohi K, Singh J, Heron M, Coats T. Acute traumatic coagulopathy. J Trauma. 2003;54(6):1127-1130. https://doi.org/10.1097/01.TA.0000069184.82147.06 PMID:12813333

Cohen MJ, Call M, Nelson M, et al. Critical role of activated protein C in early coagulopathy and later organ failure, infection and death in trauma patients. Ann Surg. 2012;255(2):379-385. https://doi.org/10.1097/SLA.0b013e318235d9e6 PMID:22133894

Ganter MT, Pittet JF. New insights into acute coagulopathy in trauma patients. Baillieres Best Pract Res Clin Anaesthesiol. 2010;24(1):15-25. https://doi.org/10.1016/j.bpa.2009.09.010PMID:20402167

Thorsen K, Ringdal KG, Strand K, Søreide E, Hagemo J, Søreide K. Clinical and cellular effects of hypothermia, acidosis and coagulopathy in major injury. Br J Surg. 2011;98(7):894-907. https://doi.org/10.1002/bjs.7497 PMID:21509749

Kornblith LZ, Moore HB, Cohen MJ. Trauma-induced coagulopathy: the past, present, and future. J Thromb Haemost. 2019;17(6):852-862. https://doi.org/10.1111/jth.14450PMID:30985957

Cardenas JC, Rahbar E, Pommerening MJ, et al. Measuring thrombin generation as a tool for predicting hemostatic potential and transfusion requirements following trauma. J Trauma Acute Care Surg. 2014;77(6):839-845. https://doi.org/10.1097/TA.0000000000000348 PMID:25099452

Hoffman M, Monroe DM III. A cell-based model of hemostasis. Thromb Haemost. 2001;85(6):958-965. https://doi.org/10.1055/s-0037-1615947 PMID:11434702

Spahn DR, Bouillon B, Cerny V, et al. The European guideline on management of major bleeding and coagulopathy following trauma: fifth edition. Crit Care. 2019 Mar 27;23(1):98. https://doi.org/10.1186/s13054-019-2347-3 PMID: 30917843

Yücel N, Lefering R, Maegele M, et al; Polytrauma Study Group of the German Trauma Society. Trauma Associated Severe Hemorrhage (TASH)-Score: probability of mass transfusion as surrogate for life threatening hemorrhage after multiple trauma. J Trauma. 2006;60(6):1228-1236. https://doi.org/10.1097/01.ta.0000220386.84012.bf PMID:16766965

Parks JK, Elliott AC, Gentilello LM, Shafi S. Systemic hypotension is a late marker of shock after trauma: a validation study of Advanced Trauma Life Support principles in a large national sample. Am J Surg. 2006;192(6):727-731. https://doi.org/10.1016/j.amjsurg.2006.08.034PMID:17161083

Johansson PI, Stensballe J, Ostrowski SR. Current management of massive hemorrhage in trauma. Scand J Trauma Resusc Emerg Med. 2012;20(20):47. https://doi.org/10.1186/1757-7241-20-47 PMID:22776724

Bocci MG, Nardi G, Veronesi G, et al. Early coagulation support protocol: A valid approach in real-life management of major trauma patients. Results from two Italian centres. Injury. 2019;50(10):1671-1677. https://doi.org/10.1016/j.injury.2019.09.032 PMID:31690405

Innerhofer P, Fries D, Mittermayr M, et al. Reversal of trauma-induced coagulopathy using first-line coagulation factor concentrates or fresh frozen plasma (RETIC): a single-centre, parallel-group, open-label, randomised trial. Lancet Haematol. 2017;4(6):e258-e271. https://doi.org/10.1016/S2352-3026(17)30077-7 PMID:28457980

Nardi G, Agostini V, Rondinelli B, et al. Trauma-induced coagulopathy: impact of the early coagulation support protocol on blood product consumption, mortality and costs. Crit Care. 2015;19(1):83. https://doi.org/10.1186/s13054-015-0817-9 PMID:25880548

Published

2022-07-31

How to Cite

1.
Bocci MG. Trauma-induced coagulopathy management. abtpn [Internet]. 2022 Jul. 31 [cited 2022 Oct. 1];9(1):77-82. Available from: https://journals.aboutscience.eu/index.php/aboutopen/article/view/2425

Issue

Section

Focus on the management of critical bleeding