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
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TLDR
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.Abstract:
Objectives: Coagulopathy following major trauma is conventionally attributed to activation and consumption of coagulation factors. Recent studies have identified an acute coagulopathy present on admission that is independent of injury severity. We hypothesized that early coagulopathy is due to tissue hypoperfusion, and investigated derangements in coagulation associated with this. 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 12, fibrinogen, thrombomodulin, protein C, plasminogen activator inhibitor-1, and D-dimers. Base deficit (BD) was used as a measure of tissue hypoperfusion. Results: A total of 208 patients were enrolled. Patients without tissue hypoperfusion were not coagulopathic, irrespective of the amount of thrombin generated. Prolongation of the partial thromboplastin and prothrombin times was only observed with an increased BD. An increasing BD was associated with high soluble thrombomodulin and low protein C levels. Low protein C levels were associated with prolongation of the partial thromboplastin and prothrombin times and hyperfibrinolysis with low levels of plasminogen activator inhibitor-1 and high D-dimer levels. High thrombomodulin and low protein C levels were significantly associated with increased mortality, blood transfusion requirements, acute renal injury, and reduced ventilator-free days. Conclusions: Early traumatic coagulopathy occurs only in the presence of tissue hypoperfusion and appears to occur without significant consumption of coagulation factors. Alterations in the thrombomodulin-protein C pathway are consistent with activated protein C activation and systemic anticoagulation. Admission plasma thrombomodulin and protein C levels are predictive of clinical outcomes following major trauma.read more
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The Ratio of Blood Products Transfused Affects Mortality in Patients Receiving Massive Transfusions at a Combat Support Hospital
Matthew A. Borgman,Philip C. Spinella,Jeremy G. Perkins,Kurt W. Grathwohl,Thomas Repine,Alec C. Beekley,James A. Sebesta,Donald H. Jenkins,Charles E. Wade,John B. Holcomb +9 more
TL;DR: In patients with combat-related trauma requiring massive transfusion, a high 1:1.4 plasma to RBC ratio is independently associated with improved survival to hospital discharge, primarily by decreasing death from hemorrhage.
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Increased plasma and platelet to red blood cell ratios improves outcome in 466 massively transfused civilian trauma patients
John B. Holcomb,Charles E. Wade,Joel E. Michalek,Gary B. Chisholm,Lee Ann Zarzabal,Martin A. Schreiber,Ernest A. Gonzalez,Gregory J. Pomper,Jeremy G. Perkins,Phillip C. Spinella,Kari L. Williams,Myung S. Park +11 more
TL;DR: The combination of high plasma and high platelet to RBC ratios were associated with decreased truncal hemorrhage, increased 6-hour, 24 hours, and 30-day survival, and increased intensive care unit, ventilator, and hospital-free days, with no change in multiple organ failure deaths.
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.
Journal ArticleDOI
Management of bleeding and coagulopathy following major trauma: an updated European guideline
Donat R. Spahn,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,Rolf Rossaint +15 more
TL;DR: Key changes encompassed in this version of the guideline include new recommendations on the appropriate use of vasopressors and inotropic agents, and reflect an awareness of the growing number of patients in the population at large treated with antiplatelet agents and/or oral anticoagulants.
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