Early Coagulopathy in Trauma: Do Coagulopathic Patients Reach the Operating Room?
Keywords:
Coagulopathy, trauma, hemorrhage, transfusion, thromboelastography
Abstract
Introduction. Acute coagulopathy in trauma results in multiple complications such as the need for blood products, higher rates of organ dysfunction, longer stay in the ICU and higher mortality. With the current knowledge of the pathophysiology of trauma and of the cellular coagulation pathway it is now possible to improve diagnosis and treatment of the initial coagulopathy and achieve better outcomes in our trauma centers.
Methods. This paper looks into the basic physiology of coagulation, and the etiology, diagnosis and treatment of early coagulopathy in trauma. The search was done using Mesh and non-Mesh terms with AND connectors: Anesthesia-coagulopathy, postinjury and trauma thromboelastography, transfusion and trauma, shock-Mechanism and trauma review.
Results. Acute or early coagulopathy in trauma is directly associated with a state of shock and is characterized by anticoagulation and systemic hyperfibrinolysis; protein C is known to be implicated in this process. It has also been determined that six multi-factorial pathophysiological mechanisms may perpetuate coagulopathy in trauma patients, namely, inflammation, acidosis, hypothermia, shock, tissue trauma and hemodilution. Diagnosis is made using the different tests (PT, PPT, platelets) that have been in use for a long time; however, these tests have drawbacks that limit their clinical usefulness. Thromboelastography can now help guide early transfusion using the best proportion of red blood cells, plasma and platelets on the basis of the best available evidence.
Conclusions. We have some knowledge about the pathophysiology coagulopathy associated with trauma but more research in this field is needed. Rapid diagnosis and immediate intervention are important to improve the outcomes with our patients.
References
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9. Stahel PF,Moore EE,Schreier SL, Flierl MA,Kashuk JL. Transfusion Strategies in Posinjury Coagulophaty. Curr Opin Anesth. 2009;22:289-298.
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11. Brohi K, Cohen MJ, Ganter MT, et al. Acute traumatic coagulopathy: initiated by hypoperfusion: modulated through the protein C pathway? Ann Surg.2007; 245:812-81.
12. Torres JC, Torres MU, Benjumea MA. Manejo de hemorragia digestiva profusa secundaria a hemangioma intestinal con factorVIIa recombinante [Reporte de caso y revisión de la literatura]. Act Colom de Cuid Inten. 2008; 8(4): 322-329.
13. Tanaka, kenichi A, Keil NS, Levy, Jerrold H. Blood Coagulation: Hemostasis and Thrombin Regulation. Anesth. & Analg. 2009 May 108(5) :1433-1446.
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18. Brummel ZK, Whelihan MF, Ziedins EG, Mann KG. Theresuscitative fluid you choose may potentiate bleeding. J Trauma. 2006;61:1350 -1358.
19. Ho AM, Karmakar MK, Dion PW. Are we giving enough coagulation factors during major trauma resuscitation?. Am J Surg 2005;190:479-484.
20. Hirshberg A, Dugas M, Banez EI, Scott BG, Wall MJ, Mattox KL. Minimizing dilutional coagulopathy in exsanguinating hemorrhage: a computer simulation. J Trauma 2003;54:454-463.
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26. Wolberg AS, Meng ZH, Monroe DM, Hoffman MA. systematic evaluation ofthe effect of temperature on coagulation enzyme activity and platelet function.J Trauma 2004; 56:1221-1228.
27. Martini WZ, Pusateri AE, Uscilowicz JM, DelgadoAV, HolcombJB. Independent contributions of hypothermia and acidosis tocoagulopathy in swine. J Trauma. [discussion] 2005;58:1009-1010.
28. Cosgriff N, Moore EE, Sauaia A,Moynihan K, Burch JM,Galloway B. Predicting life-threatening coagulopathy in the massively transfused trauma patient: hypothermia and acidoses revisited. J Trauma. [discussion] 1997;42:857- 861.
29. Martini WZ, Dubick MA, Wade CE,Holcomb JB. Evaluation of tris-hydroxymethyl aminomethane on reversing coagulation abnormalities caused by acidosis in pigs. Crit Care Med. 2007;35:1568 -1574.
30. Levi M, van der Poll T, ten Cate H, van Deventer SJ. The cytokine mediated imbalance between coagulant and anticoagulant mechanisms in sepsis and endotoxaemia. Eur J Clin Invest. 1997;27:3-9.
31. Shebuski RJ, Kilgore KS. Role of inflammatory mediators in thrombogenesis. J Pharmacol Exp Ther. 2002;300:729 -735.
32. Chesebro BB, Rahn P, Carles M,Esmon C, Jun X, Brohi K, Frith D, Pittet J-P, Cohen M. Shock. Increase in activated protein c mediates acute traumatic coagulopathy in mice. 2009 Dec ; 32 6:659-665.
33. Rugeri L, Levrat A, David JS, et al. Diagnosis of early coagulation abnormalitiesin trauma patients by rotation thrombelastography. J Thromb Haemost 2007; 5:289-295.
34. Devenport RA, Brohi K. Coagulophaty in trauma patients : Importance of thrombocyte function?.Curr Opin Anesth.2009;22:261-266.
35. Oliver M. Theusinger D R, Ganter M. Transfusion in trauma: why and how should we change our current practice? Curr Opn Anaesth 2009,22:000-000.
36. Feliciano DV, Mattox K, Moore E. Trauma, 6th Edition: McGraw-Hill ;2008.
37. Dutton RP. Current Concepts in Hemorrhagic Shock. Anesth Clinics 2007 March 1; 25 :23-34.
38. American College of Surgeons Committee on Trauma: Advanced Trauma Life Support(ATLS)Course for Physicians,edn 7.Chicago:American College of Surgeons;2008.
39. Sorensen B, Ingerslev J. Tailoring haemostatic treatment to patient requirements - an update on monitoring haemostatic response using thrombelastography. (Suppl) Haemophilia 2005 11; 1:1-6.
40. Brown RB, Klar J, Teres D, Lemeshow S, Sands M. Prospective study of clinical bleeding in intensive care unit patients. Crit Care Med. 1988 Dec 16(12):1171-6.
41. Stein D, Dutton R, Kramer M, Scalea T. Reversal of Coagulopathy in Critically Ill Patients With Traumatic Brain Injury: recombinant Factor VIIa is More Cost-Effective Than Plasma. J Trauma 2009;66: 63-75.
42. Galvan DA,Fink MP. Recombinant factor VIIa in severe trauma: Further study needed. Crit care 2006 10:308.
43. Martinowitz U, Holcomb JB, Pusateri AE, et al. Intravenous rFVIIa administered for hemorrhage control in hypothermic coagulopathic swine ith grade V liver injuries. J Trauma 2001; 50:721-729.
44. Bartal C, Yitzha A. The role of thromboelastometry and recombinant factor VIIa in trauma, Curr Opin Anaesthesiol 2009 Apr; 22(2):281-288.
45. Hellstern P, Halbmayer WM, Kohler M et al. Prothrombin complex concentrates: indications, contraindications, and risks: a task force summary. Thromb Res 1999; 95:S3-S6.
46. Blauhut B. Indications for prothrombin complex concentrates in massive transfusions. Thromb Res 1999; 95:S63-S69.
47. Schulman S, Bijsterveld NR. Anticoagulants and their reversal. Transfusion Medicine Reviews 2007; 21: 37-48.
48. Van Veen SQ, Strengers PF. Use of prothrombin complex concentrates in anticoagulation. Am J Hematol 2008; 83:344-345.
49. Esmon CT. Crosstalk between inflammation and thrombosis.Maturitas. 2004;47:305-314.
50. Rigby AC, Grant MA. Protein S: a conduit between anticoagulation and inflammation. Crit Care Med. 2004;32:S336 -S341.
2. Charles A, Shaikh AA, Walters M, Huehl S, Pomerantz R. Bloodtransfusion is an independent predictor of mortality after blunttrauma. Am Surg. 2007;73:1-5.
3. Kheirabadi BS, Crissey JM, Deguzman R, Holcomb JB. In vivobleeding time and in vitro thrombelastography measurements are better indicators of dilutional hypothermic coagulopathy thanprothrombin time.J rauma.2007;62:1352-1359.
4. Rugeri L, Levrat A, David JS, et al. Diagnosis of early coagulation abnormalities in trauma patients by rotation thrombelastography.JThrombHaemost. 2007;5:289 -295.
5. Borgman MA, Spinella PC, Perkins JG, et al. The ratio of bloodproducts transfused affects mortality in patients receiving massive transfusions at a combat support hospital. J Trauma. 2007;63:805- 813.
6. Sauaia A, Moore FA, Moore EE, et al. Epidemiology of trauma deaths: a Reassessment. J Trauma. 1995; 38(2):185-193.
7. MacLeod JB, Lynn M, McKenney M, Cohn S, Murtha M. Early coagulopathy predicts mortality in trauma. J Trauma. 2003; 55(1):39-44.
8. Brohi K, Singh J, Heron M, Coats T. Acute traumatic coagulopathy. J.Trauma.2003;54(6):1127-1130.
9. Stahel PF,Moore EE,Schreier SL, Flierl MA,Kashuk JL. Transfusion Strategies in Posinjury Coagulophaty. Curr Opin Anesth. 2009;22:289-298.
10. Brohi K, Cohen MJ, Ganter MT, et al. Acute coagulopathy of trauma: hypoperfusion induces systemic anticoagulation and hyperfibrinolysis. J Trauma.2008; 64:1211-1217.
11. Brohi K, Cohen MJ, Ganter MT, et al. Acute traumatic coagulopathy: initiated by hypoperfusion: modulated through the protein C pathway? Ann Surg.2007; 245:812-81.
12. Torres JC, Torres MU, Benjumea MA. Manejo de hemorragia digestiva profusa secundaria a hemangioma intestinal con factorVIIa recombinante [Reporte de caso y revisión de la literatura]. Act Colom de Cuid Inten. 2008; 8(4): 322-329.
13. Tanaka, kenichi A, Keil NS, Levy, Jerrold H. Blood Coagulation: Hemostasis and Thrombin Regulation. Anesth. & Analg. 2009 May 108(5) :1433-1446.
14. John RH, Brohi K, Richard PD,Carl JH, John BH , Kluger Y,Mackway K, Par M, , Rizoli SB , Yukioka T , Hoyt DB, Bouillon B. The Coagulopathy of Trauma: A Review of Mechanisms. J Trauma. 2008;65:748 -754.
15. Esmon CT. The interactions between inflammation and coagulation.Bj J Haematol.2005;131:417-430.
16. Mann KG. Biochemistry and physiology of blood coagulation.Thromb Haemost. 1999;82:165-174.
17. Siegel JH, Rivkind AI, Dalal S, et al. Early physiologic predictors of injur Severity and death in blunt multiple trauma. Arch Surg 1990; 125:498-508.
18. Brummel ZK, Whelihan MF, Ziedins EG, Mann KG. Theresuscitative fluid you choose may potentiate bleeding. J Trauma. 2006;61:1350 -1358.
19. Ho AM, Karmakar MK, Dion PW. Are we giving enough coagulation factors during major trauma resuscitation?. Am J Surg 2005;190:479-484.
20. Hirshberg A, Dugas M, Banez EI, Scott BG, Wall MJ, Mattox KL. Minimizing dilutional coagulopathy in exsanguinating hemorrhage: a computer simulation. J Trauma 2003;54:454-463.
21. Brazil EV, Coats TJ. Sonoclot coagulation analysis of in-vitro haemodilution with resuscitation solutions. J R Soc Med 2000;93:507-510.
22. Vincent JL, Rossaint R, Riou B, Ozier Y, Zideman D, Spahn DR. Recommendations on the use of rFVIIa as an adjunctive treatment for massive bleeding -a European perspective. Critical Care 2006; 10: R120.
23. Reed RL II, Bracey AW, Jr., Hudson JD, Miller TA, Fischer RP.Hypothermia and blood coagulation: dissociation between enzyme activity and clotting factor levels. Circ Shock. 1990;32:141-152.
24. Wolberg AS, Meng ZH, Monroe DM III, Hoffman M. A systematic evaluation of the effect of temperature on coagulation enzyme activity and platelet function. J Trauma. 2004;56:1221-1228.
25. Meng ZH, Wolberg AS, Monroe DM III, Hoffman M. The effect oftemperature and pH on the activity of factor VIIa: implications forthe efficacy of high-dose factor VIIa in hypothermic and acidoticpatients. J Trauma. 2003;55:886-891.
26. Wolberg AS, Meng ZH, Monroe DM, Hoffman MA. systematic evaluation ofthe effect of temperature on coagulation enzyme activity and platelet function.J Trauma 2004; 56:1221-1228.
27. Martini WZ, Pusateri AE, Uscilowicz JM, DelgadoAV, HolcombJB. Independent contributions of hypothermia and acidosis tocoagulopathy in swine. J Trauma. [discussion] 2005;58:1009-1010.
28. Cosgriff N, Moore EE, Sauaia A,Moynihan K, Burch JM,Galloway B. Predicting life-threatening coagulopathy in the massively transfused trauma patient: hypothermia and acidoses revisited. J Trauma. [discussion] 1997;42:857- 861.
29. Martini WZ, Dubick MA, Wade CE,Holcomb JB. Evaluation of tris-hydroxymethyl aminomethane on reversing coagulation abnormalities caused by acidosis in pigs. Crit Care Med. 2007;35:1568 -1574.
30. Levi M, van der Poll T, ten Cate H, van Deventer SJ. The cytokine mediated imbalance between coagulant and anticoagulant mechanisms in sepsis and endotoxaemia. Eur J Clin Invest. 1997;27:3-9.
31. Shebuski RJ, Kilgore KS. Role of inflammatory mediators in thrombogenesis. J Pharmacol Exp Ther. 2002;300:729 -735.
32. Chesebro BB, Rahn P, Carles M,Esmon C, Jun X, Brohi K, Frith D, Pittet J-P, Cohen M. Shock. Increase in activated protein c mediates acute traumatic coagulopathy in mice. 2009 Dec ; 32 6:659-665.
33. Rugeri L, Levrat A, David JS, et al. Diagnosis of early coagulation abnormalitiesin trauma patients by rotation thrombelastography. J Thromb Haemost 2007; 5:289-295.
34. Devenport RA, Brohi K. Coagulophaty in trauma patients : Importance of thrombocyte function?.Curr Opin Anesth.2009;22:261-266.
35. Oliver M. Theusinger D R, Ganter M. Transfusion in trauma: why and how should we change our current practice? Curr Opn Anaesth 2009,22:000-000.
36. Feliciano DV, Mattox K, Moore E. Trauma, 6th Edition: McGraw-Hill ;2008.
37. Dutton RP. Current Concepts in Hemorrhagic Shock. Anesth Clinics 2007 March 1; 25 :23-34.
38. American College of Surgeons Committee on Trauma: Advanced Trauma Life Support(ATLS)Course for Physicians,edn 7.Chicago:American College of Surgeons;2008.
39. Sorensen B, Ingerslev J. Tailoring haemostatic treatment to patient requirements - an update on monitoring haemostatic response using thrombelastography. (Suppl) Haemophilia 2005 11; 1:1-6.
40. Brown RB, Klar J, Teres D, Lemeshow S, Sands M. Prospective study of clinical bleeding in intensive care unit patients. Crit Care Med. 1988 Dec 16(12):1171-6.
41. Stein D, Dutton R, Kramer M, Scalea T. Reversal of Coagulopathy in Critically Ill Patients With Traumatic Brain Injury: recombinant Factor VIIa is More Cost-Effective Than Plasma. J Trauma 2009;66: 63-75.
42. Galvan DA,Fink MP. Recombinant factor VIIa in severe trauma: Further study needed. Crit care 2006 10:308.
43. Martinowitz U, Holcomb JB, Pusateri AE, et al. Intravenous rFVIIa administered for hemorrhage control in hypothermic coagulopathic swine ith grade V liver injuries. J Trauma 2001; 50:721-729.
44. Bartal C, Yitzha A. The role of thromboelastometry and recombinant factor VIIa in trauma, Curr Opin Anaesthesiol 2009 Apr; 22(2):281-288.
45. Hellstern P, Halbmayer WM, Kohler M et al. Prothrombin complex concentrates: indications, contraindications, and risks: a task force summary. Thromb Res 1999; 95:S3-S6.
46. Blauhut B. Indications for prothrombin complex concentrates in massive transfusions. Thromb Res 1999; 95:S63-S69.
47. Schulman S, Bijsterveld NR. Anticoagulants and their reversal. Transfusion Medicine Reviews 2007; 21: 37-48.
48. Van Veen SQ, Strengers PF. Use of prothrombin complex concentrates in anticoagulation. Am J Hematol 2008; 83:344-345.
49. Esmon CT. Crosstalk between inflammation and thrombosis.Maturitas. 2004;47:305-314.
50. Rigby AC, Grant MA. Protein S: a conduit between anticoagulation and inflammation. Crit Care Med. 2004;32:S336 -S341.
How to Cite
1.
Jiménez B. JC, de La Peña L. J, Teherán M. R, Orozco A. Early Coagulopathy in Trauma: Do Coagulopathic Patients Reach the Operating Room?. Colomb. J. Anesthesiol. [Internet]. 2010 Oct. 1 [cited 2024 Apr. 26];38(4):510-25. Available from: https://www.revcolanest.com.co/index.php/rca/article/view/806
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2010-10-01
How to Cite
1.
Jiménez B. JC, de La Peña L. J, Teherán M. R, Orozco A. Early Coagulopathy in Trauma: Do Coagulopathic Patients Reach the Operating Room?. Colomb. J. Anesthesiol. [Internet]. 2010 Oct. 1 [cited 2024 Apr. 26];38(4):510-25. Available from: https://www.revcolanest.com.co/index.php/rca/article/view/806
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Narrative review
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