Coagulation management in the treatment of multiple trauma

Abstract

In recent years a new understanding of trauma-associated hemorrhaging and trauma-induced coagulopathy has been achieved. This coagulopathy is multifactorial with the predominant mechanisms being tissue trauma, shock and hypoperfusion which can lead to hyperfibrinolysis by activation of the endothelium. Routinely tested coagulation parameters, such as prothrombin time and partial thromboplastin time, are frequently employed for decision making but remain problematic as they do not give any information on clot stability, lysis or platelet function. Thrombelastometry seems to be a useful alternative. A pro-active anticipatory approach is required for a successful outcome to be achieved as rescue correction is more difficult than prevention. While the pathophysiological conception of causal relationship of the mentioned therapeutic options is conclusive, an evidence-based validation by randomized controlled studies is mostly lacking. The emergency and anesthesiological concept of damage control resuscitation consists of limiting volume therapy with crystalloids and colloids to reach a mean arterial pressure > or =65 mmHg (higher for head injuries), active (re-)warming management, the prevention of a pH< or =7.2 and a base excess (BE) < or =-6 mmol/l. The early and sufficient application of hemostatic drugs is essential. Because erythrocytes play a substantial role in the coagulation process, hemoglobin (Hb) values of around 6. 2 mmol/l (10 g/dl) and/or a hematocrit of 30% should be strived for when massive non-arrested hemorrhaging occurs. After severe multiple trauma a fibrinogen deficit develops and must be adequately compensated. If coagulation therapy is carried out using fresh frozen plasma sufficient quantities (20-30 ml/kgBW) must be administered to correspondingly raise the coagulation factors. Prothrombin complex concentrates can be helpful to optimize thrombin generation during severe hemorrhaging. Because hyperfibrinolysis occurs more often than previously assumed during severe trauma, an anti-fibrinolytic therapy should be used especially for patients with an instable circulation. The platelet count should not go below 100,000/microl when hemorrhaging occurs after multiple trauma. For thrombocytopathic patients with diffuse bleeding desmopressin (DDAVP) is a therapeutic option and the "off label" use of recombinant activated factor VIIa (rFVIIa) remains an option for individual situations with stringent indications and when the above named measures to optimize the coagulation situation have been taken.

The use of viscoelastic haemostatic assays in goal-directing treatment with allogeneic blood products – A systematic review and meta-analysis

“…Manuscript not available for reading. Contact information of corresponding author not available.Karkouti 2016 [61]Cardiac surgeryStepped-Wedge Clustered RCTLevin 2014 [62]Cardiac surgeryFocus on protamine-administrationLier 2009 [63]TraumaReviewMallaiah 2015 [64]Obstetric haemorrhageBefore-after trialManikappa 2011 [65]Cardiac surgeryWhole blood transfusionsMessenger 2011 [66]TraumaProspective cohort studyMishra 2015 [67]Cardiac surgeryFocus on platelet function testingNaik 2015 [68]Major spinal surgeryNon-randomisedPetricevic 2013 [69]Cardiac surgeryObservational trialRahe-Meyer 2009 [70]Aortic surgeryNon-randomisedRoullet 2015 [71]Orthotopic liver transplantationNon-randomisedSmart 2015 [72]Orthotopic liver transplantationRetrospective non-randomised trialStancheva 2011 [73]Orthotopic liver transplantationObservational trialTarabarin 2013 [74]Bile duct surgeryPossibly relevant. Manuscript not available for reading.…”

Factors that may improve outcomes of early traumatic brain injury care: prospective multicenter study in Austria

“…This recommendation was based on the finding that during Phase 1, patients who had had TEM in the Trauma Room had higher hospital survival (51 % vs. 38 %) and a higher rate of favorable outcome (40 % vs. 28 %). A number of recent studies suggest that the use of TEM to guide coagulation management may be beneficial after multiple trauma [ 28 , 29 ] as well as after TBI [ 30 ]. The significant increase in early use of TEM during Phase 2 may have contributed to the better outcomes of the Phase 2 patients.…”

Aktuelle interdisziplinäre Handlungsempfehlungen bei schweren peri-(post-)partalen Blutungen (PPH)

“…Darüber hinaus sollte eine metabolische Azidose (pH ≤ 7,2) korrigiert und das ionisierte Tab. 4 Mögliche Klassifikation der PPH nach Blutverlust und klinischen Symptomen (zusammengefasst nach [22,31,33] Kalzium (50% des Gesamtkalziums, Norm: 1,2 mmol/l) im Normbereich gehalten werden (Cave: ionisiertes Kalzium ≤ 0,9 mmol/l, Grad-D-Empfehlung [43,46]).…”