Acute Coagulopathy of Trauma: Hypoperfusion Induces Systemic Anticoagulation and Hyperfibrinolysis
Karim Brohi,Mitchell J. Cohen,Michael T. Ganter,Marcus J. Schultz,Marcel Levi,Robert C. Mackersie,Jean-Francois Pittet +6 more
TLDR
Acute coagulopathy of trauma is associated with systemic hypoperfusion and is characterized by anticoagulation and hyperfibrinolysis, which correlates with thrombomodulin activity.Abstract:
BACKGROUND: Coagulopathy is present at admission in 25% of trauma patients, is associated with shock and a 5-fold increase in mortality. The coagulopathy has recently been associated with systemic activation of the protein C pathway. This study was designed to characterize the thrombotic, coagulant and fibrinolytic derangements of trauma-induced shock. METHODS: This was a prospective cohort study of major trauma patients admitted to a single trauma center. Blood was drawn within 10 minutes of arrival for analysis of partial thromboplastin and prothrombin times, prothrombin fragments 1 + 2 (PF1 + 2), fibrinogen, factor VII, thrombomodulin, protein C, plasminogen activator inhibitor-1 (PAI-1), thrombin activatable fibrinolysis inhibitor (TAFI), tissue plasminogen activator (tPA), and D-dimers. Base deficit was used as a measure of tissue hypoperfusion. RESULTS: Two hundred eight patients were studied. Systemic hypoperfusion was associated with anticoagulation and hyperfibrinolysis. Coagulation was activated and thrombin generation was related to injury severity, but acidosis did not affect Factor VII or PF1 + 2 levels. Hypoperfusion-induced increase in soluble thrombomodulin levels was associated with reduced fibrinogen utilization, reduction in protein C and an increase in TAFI. Hypoperfusion also resulted in hyperfibrinolysis, with raised tPA and D-Dimers, associated with the observed reduction in PAI-1 and not alterations in TAFI. CONCLUSIONS: Acute coagulopathy of trauma is associated with systemic hypoperfusion and is characterized by anticoagulation and hyperfibrinolysis. There was no evidence of coagulation factor loss or dysfunction at this time point. Soluble thrombomodulin levels correlate with thrombomodulin activity. Thrombin binding to thrombomodulin contributes to hyperfibrinolysis via activated protein C consumption of PAI-1.read more
Citations
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Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo-controlled trial
TL;DR: Tranexamic acid safely reduced the risk of death in bleeding trauma patients in this study, and should be considered for use in bleed trauma patients.
Journal ArticleDOI
The European guideline on management of major bleeding and coagulopathy following trauma: fourth edition
Rolf Rossaint,Bertil Bouillon,Vladimir Cerny,Timothy J Coats,Jacques Duranteau,Enrique Fernández-Mondéjar,Daniela Filipescu,Beverley J. Hunt,Radko Komadina,Giuseppe Nardi,Edmund Neugebauer,Yves Ozier,Louis Riddez,Arthur Schultz,Jean Louis Vincent,Donat R. Spahn +15 more
TL;DR: The guideline now recommends that patients be transferred directly to an appropriate trauma treatment centre and encourages use of a restricted volume replacement strategy during initial resuscitation, and may also serve as a basis for local implementation.
Journal ArticleDOI
The importance of early treatment with tranexamic acid in bleeding trauma patients: an exploratory analysis of the CRASH-2 randomised controlled trial.
Ian Roberts,Haleema Shakur,AO Afolabi,Karim Brohi,Timothy J Coats,Yashbir Dewan,Satoshi Gando,Gordon H. Guyatt,Beverley J. Hunt,Carlos Morales,Pablo Perel,David Prieto-Merino,Tom Woolley +12 more
TL;DR: Strong evidence is recorded that tranexamic acid should be given as early as possible to bleeding trauma patients with significant haemorrhage, and for trauma patients admitted late after injury, tranExamic acid is less effective and could be harmful.
Journal ArticleDOI
Acute traumatic coagulopathy.
TL;DR: Conventional concepts of traumatic coagulopathy as a late occurring condition in response to iatrogenic haemodilution are redundant and ATC is an endogenous impairment of haemostasis that begins at the moment of injury.
Journal ArticleDOI
The coagulopathy of trauma: a review of mechanisms.
John R. Hess,Karim Brohi,Richard P. Dutton,Carl J. Hauser,John B. Holcomb,Yoram Kluger,Kevin Mackway-Jones,Michael Parr,Sandro Rizoli,Tetsuo Yukioka,David B. Hoyt,Bertil Bouillon +11 more
TL;DR: There is limited understanding of the mechanisms by which tissue trauma, shock, and inflammation initiate trauma coagulopathy, and Acute Coagulopathic of Trauma-Shock should be considered distinct from disseminated intravascular coagulation as described in other conditions.
References
More filters
Journal ArticleDOI
Acute traumatic coagulopathy.
TL;DR: There is a common and clinically important acute traumatic coagulopathy that is not related to fluid administration that is related to mortality and a coagulation screen is an important early test in severely injured patients.
Journal ArticleDOI
A prospective study of venous thromboembolism after major trauma.
TL;DR: Venous thromboembolism is a common complication in patients with major trauma, and effective, safe prophylactic regimens are needed.
Journal ArticleDOI
Acute traumatic coagulopathy: initiated by hypoperfusion: modulated through the protein C pathway?
Karim Brohi,Mitchell J. Cohen,Michael T. Ganter,Michael A. Matthay,Robert C. Mackersie,Jean-Francois Pittet +5 more
TL;DR: Early traumatic coagulopathy occurs only in the presence of tissue hypoperfusion and appears to occur without significant consumption of coagulation factors, which is consistent with activated protein C activation and systemic anticoagulation.
Journal ArticleDOI
Recombinant factor VIIa as adjunctive therapy for bleeding control in severely injured trauma patients: two parallel randomized, placebo-controlled, double-blind clinical trials.
Kenneth D. Boffard,Bruno Riou,Brian Warren,Philip Iau Tsau Choong,Sandro Rizoli,Rolf Rossaint,Mads Axelsen,Yoram Kluger +7 more
TL;DR: Recombinant FVIIa resulted in a significant reduction in RBC transfusion in severe blunt trauma and the safety of rFVIIa was established in these trauma populations within the investigated dose range.
Journal ArticleDOI
Acute Coagulopathy of Trauma: Hypoperfusion Induces Systemic Anticoagulation and Hyperfibrinolysis
Karim Brohi,Mitchell J. Cohen,Michael T. Ganter,Marcus J. Schultz,Marcel Levi,Robert C. Mackersie,Jean-Francois Pittet +6 more
TL;DR: Acute coagulopathy of trauma is associated with systemic hypoperfusion and is characterized by anticoagulation and hyperfibrinolysis, which correlates with thrombomodulin activity.