Transfusion strategies for major haemorrhage in trauma

Abstract

Summary Trauma is a leading cause of death worldwide in persons under 44 years of age, and uncontrolled haemorrhage is the most common preventable cause of death in this patient group. The transfusion management of trauma haemorrhage is unrecognisable from 20 years ago. Changes in clinical practice have been driven primarily by an increased understanding of the pathophysiology of trauma‐induced coagulopathy (TIC), which is associated with poor clinical outcomes, including a 3‐ to 4‐fold increased risk of death. Targeting this coagulopathy alongside changes to surgical and anaesthetic practices (an overarching strategy known as damage control surgery/damage control resuscitation) has led to a significant reduction in mortality rates over the last two decades. This narrative review will discuss the transfusion practices that are currently used for trauma haemorrhage and the evidence that supports these practices.

Diagnosis and Treatment of Trauma-Induced Coagulopathy by Viscoelastography

“…As a result, normal values vary by location, and protocols for BCT do not have standardized cutoffs for the initiation of treatment. 31,36,38,40…”

“…Based on this new data and ongoing RCTs regarding VET use in trauma, it is anticipated that VETs will become the standard of care. 21,26,[29][30][31][32][33][34][35][36] Fig . 1 The analogy is that in the surgical/emergency "silo," BCT in trauma patients is guided by VETs while in the medical "silo," BCT is driven by CCTs.…”

Use of Viscoelastography in Malignancy-Associated Coagulopathy and Thrombosis: A Review

“…This leads to what has been called by Johansson et al as SHock INduced Endotheliopathy (SHINE). 27,50 This glycocalyx breakdown signals further endothelial activation and results in systemic autoheparinization as evidenced by increased expression of syndecan-1. 49 (C) Similar to the glycocalyx hypothesis's focus on endothelium injury from hypoperfusion, the protein C activation hypothesis also proposes that endothelium injury and/or hypoperfusion results in an anticoagulant state.…”

“…38,156 Potential use of Precision-Based Medicine in MAC and TIC Large randomized controlled trials regarding the empiric management of bleeding trauma and obstetrical patients have been met with differing levels of acceptances as the histories of the CRASH-2 and WOMAN trials have shown. 27,[157][158][159][160][161][162][163] Because of the unintended consequence of "one-size-fits-all" randomized controlled trial philosophy touted for the advancement of evidence-based clinical science, it is more difficult to engage in smaller proof-of-concept studies that evaluate the influence of specific pathophysiological derangements and phenotypes on clinical outcomes. 164,165 The concept of precision-based medicine has been developed to allow for the integration of epidemiologic findings from randomized controlled trials with select patient-group-specific clinical findings.…”

“…3,23,24 Recent literature has indicated that in noncancerous states, such as critically ill, septic, and postoperative states, VETs are useful in identifying a hypercoagulable state and guiding resuscitation. [23][24][25][26][27][28][29] The use of VETs to guide hemostatic resuscitation of patients with trauma-induced coagulopathy (TIC) has also led to these point-of-care tests being used as predictors of thromboembolism and multiorgan failure (MOF) in trauma patients during the postresuscitation period. [30][31][32][33][34] The utility of these assays has now been extended to surgical oncology patients with colon, rectal, and breast cancer who present with seemingly normal fibrinogen and platelets.…”