Trauma-Induced Coagulopathy: An Institution’s 35 Year Perspective on Practice and Research

Abstract

Introduction Injury is the second leading cause of death worldwide, and as much as 40% of injury-related mortality is attributed to uncontrollable hemorrhage. This persists despite establishment of regionalized trauma systems and advances in the management of severely injured patients. Trauma-induced coagulopathy has been identified as the most common preventable cause of postinjury mortality. Methods A review of the current literature was performed by collecting PUBMED references related to trauma-induced coagulopathy. Data were then critically analyzed and summarized based on the authors’ clinical and research perspective, as well as that reported by other institutions and researchers interested in trauma-induced coagulopathy. A particular focus was placed on those aspects of coagulopathy in which agreement among clinical and basic scientists is currently lacking; these include, pathophysiology, the role of blood components and factor therapy, and goal-directed assessment and management. Results Trauma-induced coagulopathy has been recognized in approximately one-third of trauma patients. There is a vast range of severity, and the emergence of viscoelastic assays, such as thrombelastography and rotational thromboelastogram, has refined its diagnosis and management, particularly through the establishment of goal-directed massive transfusion protocols. Despite advancements in the diagnosis and management of trauma-induced coagulopathy, much remains to be understood regarding its pathophysiology. The cell-based model of hemostasis has allowed for characterization of endothelial dysfunction, impaired thrombin generation, platelet dysfunction, fibrinolysis, endogenous anticoagulants such as protein-C, and antifibrinolytic proteins. These concepts collectively compose the contemporary, but still partial, understanding of trauma-induced coagulopathy. Conclusion Trauma-induced coagulopathy is a complex pathophysiological condition, of which some mechanisms have been characterized, but much remains to be understood in order to translate this knowledge into improved outcomes for the injured patient.

Elevated admission international normalized ratio strongly predicts mortality in victims of abusive head trauma

“…28,[40][41][42] However, the implications of this maladaptive response for pediatric trauma populations is unclear, as all of these studies come from an adult population. Factor pathways and normal laboratory ranges are established based on an adult population, but it is inappropriate to extrapolate best practice for the pediatric population from this data.…”

Mechanisms of early trauma-induced coagulopathy

“…18,22Y24 Others prefer acute coagulopathy of trauma (ACoT), acute coagulopathy of trauma/shock (ACoTs), 30,32 trauma-induced coagulopathy, or early trauma-induced coagulopathy. 33,34 Based on the available data, it seems timely for a global consensus on a name and acronym to reduce unnecessary confusion in the literature. TIC or ATC seem to be suitable candidates (Fig.…”

Early hemorrhage triggers metabolic responses that build up during prolonged shock

“…Metabolic acidosis and coagulopathy are, indeed, deeply intertwined (14,34). Recent studies identifying postinjury fibrinolysis using thrombelastography (TEG) have refined the degree of clot lysis that is associated with adverse outcomes from Ͼ15% to Ͼ3% (21). However, no observational evidence has been reported so far about the potential correlation of metabolome profiles and fibrinolysis.…”