Understanding Of Trauma-induced Coagulopathy Research Articles

Is Fresh Frozen Plasma Still Necessary for Management of Acute Traumatic Coagulopathy?

Massive blood loss secondary to major trauma is a leading cause of death worldwide. In recent years, multiple different strategies have evolved to counteract this life-threatening condition. In this review, we will review our understanding of trauma-induced coagulopathy and summarize current clinical transfusion regimes utilized in military and civilian settings. We will review currently available blood products used to rectify the coherent disturbances of haemostasis by outlining the characteristics of the different products. Current evidence suggests that fresh frozen plasma and fibrinogen components play a fundamental role in trauma resuscitation with recent studies suggesting pre-hospital plasma and fibrinogen administration might also be beneficial in counteracting trauma-induced coagulopathy. Based on experience out of combat zones, whole blood transfusion might experience a renaissance in the future. Multiple different plasma-based products are available to treat and prevent trauma-induced coagulation disturbances. As randomized controlled trials in trauma population are difficult to conduct, most of the evidence is currently based on relatively small studies. While the overarching result of our review suggests the early use of plasma and fibrinogen products in combination with packed red blood cells will prevent trauma-induced coagulopathy, large, multi-centre studies are warranted to evaluate the long-term effects on patients’ outcome.

The current understanding of trauma-induced coagulopathy (TIC): a focused review on pathophysiology.

The emergency management of acute severe bleeding in trauma patients has changed significantly in recent years. In particular, greater attention is now being devoted to a prompt assessment of coagulation alterations, which allows for immediate haemostatic resuscitation procedures when necessary. The importance of an early trauma-induced coagulopathy (TIC) diagnosis has led physicians to increase the efforts to better understand the pathophysiological alterations observed in the haemostatic system after traumatic injuries. As yet, the knowledge of TIC is not exhaustive, and further studies are needed. The aim of this review is to gather all the currently available data and information in an attempt to gain a better understanding of TIC. A comprehensive literature search was performed using MEDLINE database. The bibliographies of relevant articles were screened for additional publications. In major traumas, coagulopathic bleeding stems from a complex interplay among haemostatic and inflammatory systems, and is characterized by a multifactorial dysfunction. In the abundance of biochemical and pathophysiological changes occurring after trauma, it is possible to discern endogenously induced primary predisposing conditions and exogenously induced secondary predisposing conditions. TIC remains one of the most diagnostically and therapeutically challenging condition.

Mechanisms of trauma-induced coagulopathy.

Hemorrhage is the leading cause of potentially preventable death following injury. Excessive and uncontrolled bleeding, commonly referred to as trauma-induced coagulopathy (TIC), affects a quarter of all trauma patients and is associated with substantial injuries, increased transfusion requirements, and poor outcomes. Recent data have contributed to our current understanding of the molecular mechanisms driving TIC. The current literature offers evidence supporting proposed mechanisms that induce TIC, such as platelet dysfunction, endogenous anticoagulation, endothelial activation, fibrinogen modifications, and hyperfibrinolysis. However, the majority of these data are mere associations; causative data are slowly unfolding through the utilization of animal models of hemorrhagic shock coupled with prospective observational clinical studies. As both clinical and basic science research expands our understanding of TIC, trauma patient care is improving substantially. Future studies should focus on the interplay between the coagulation pathways whose simultaneous or codependent dysregulation could offer the most advantageous points for intervention.

Coagulation management in multiple trauma: a systematic review

The management of trauma patients suffering from active bleeding has improved with a better understanding of trauma-induced coagulopathy. The aim of this manuscript is to give recommendations for coagulation management. A systematic literature search in the PubMed database was performed for articles published between January 2000 and August 2009. A total of 230 articles were included in the present systematic review. The "coagulopathy of trauma" is a discrete disease which has a decisive influence on survival. Diagnosis and therapy of deranged coagulation should start immediately after admission to the emergency department. A specific protocol for massive transfusion should be introduced and continued. Loss of body temperature should be prevented and treated. Acidaemia should be prevented and treated by appropriate shock therapy. If massive transfusion is performed using fresh frozen plasma (FFP), a ratio of FFP to pRBC (packed red blood cells) of 1:2-1:1 should be achieved. Fibrinogen should be substituted at levels of <1.5 g/L. For patients suffering from active bleeding, permissive hypotension (i.e. mean arterial pressure ~65 mmHg) may be aimed for until surgical cessation of bleeding. This option is contraindicated in injuries of the central nervous system and in patients with coronary heart disease, or with known hypertension. Thrombelastography or -metry may be performed to guide coagulation diagnosis and substitution. Hypocalcaemia <0.9 mmol/L should be avoided and may be treated. For actively bleeding patients, pRBC may be given at haemoglobin <10 g/L (6.2 mmol/L) and haematocrit may be targeted at 30%.

Transfusion Management of Trauma Patients

The management of massively transfused trauma patients has improved with a better understanding of trauma-induced coagulopathy, the limitations of crystalloid infusion, and the implementation of massive transfusion protocols (MTPs), which encompass transfusion management and other patient care needs to mitigate the "lethal triad" of acidosis, hypothermia, and coagulopathy. MTPs are currently changing in the United States and worldwide because of recent data showing that earlier and more aggressive transfusion intervention and resuscitation with blood components that approximate whole blood significantly decrease mortality. In this context, MTPs are a key element of "damage control resuscitation," which is defined as the systematic approach to major trauma that addresses the lethal triad mentioned above. MTPs using adequate volumes of plasma, and thus coagulation factors, improve patient outcome. The ideal amounts of plasma, platelet, cryoprecipitate and other coagulation factors given in MTPs in relationship to the red blood cell transfusion volume are not known precisely, but until prospective, randomized, clinical trials are performed and more clinical data are obtained, current data support a target ratio of plasma:red blood cell:platelet transfusions of 1:1:1. Future prospective clinical trials will allow continued improvement in MTPs and thus in the overall management of patients with trauma.