Hypoperfusion in severely injured trauma patients is associated with reduced coagulation factor activity

Exploratory Investigation of the Plasma Proteome Associated with the Endotheliopathy of Trauma

BACKGROUND

The endotheliopathy of trauma (EoT) is associated with increased mortality following injury. Herein, we describe the plasma proteome related to EoT in order to provide insight into the role of the endothelium within the systemic response to trauma.

METHODS

99 subjects requiring the highest level of trauma activation were included in the study. Enzyme-linked immunosorbent assays of endothelial and catecholamine biomarkers were performed on admission plasma samples, as well as untargeted proteome quantification utilizing high-performance liquid chromatography and tandem mass spectrometry.

RESULTS

Plasma endothelial and catecholamine biomarker abundance was elevated in EoT. Patients with EoT (n = 62) had an increased incidence of death within 24 h at 21% compared to 3% for non-EoT (n = 37). Proteomic analysis revealed that 52 out of 290 proteins were differentially expressed between the EoT and non-EoT groups. These proteins are involved in endothelial activation, coagulation, inflammation, and oxidative stress, and include known damage-associated molecular patterns (DAMPs) and intracellular proteins specific to several organs.

CONCLUSIONS

We report a proteomic profile of EoT suggestive of a surge of DAMPs and inflammation driving nonspecific activation of the endothelial, coagulation, and complement systems with subsequent end-organ damage and poor clinical outcome. These findings support the utility of EoT as an index of cellular injury and delineate protein candidates for therapeutic intervention.

Trauma-Induced Coagulopathy: Overview of an Emerging Medical Problem from Pathophysiology to Outcomes

Coagulopathy induced by major trauma is common, affecting approximately one-third of patients after trauma. It develops independently of iatrogenic, hypothermic, and dilutive causes (such as iatrogenic cause in case of fluid administration), which instead have a pejorative aspect on coagulopathy. Notwithstanding the continuous research conducted over the past decade on Trauma-Induced Coagulopathy (TIC), it remains a life-threatening condition with a significant impact on trauma mortality. We reviewed the current evidence regarding TIC diagnosis and pathophysiological mechanisms and summarized the different iterations of optimal TIC management strategies among which product resuscitation, potential drug administrations, and hemostatis-focused approaches. We have identified areas of ongoing investigation and controversy in TIC management.

A Selection of Trauma Scores Might Not Correlate with Coagulation Factor Activity following Multiple Injuries: A Retrospective Observational Study from a Level 1 Trauma Center

Loss and dilution of coagulation factors have been observed following multiple trauma. Timely recognition of reduced clotting factor activity might facilitate therapeutic action to restore normal coagulation function. This study investigates the potential role of some well-known trauma scores in predicting coagulation factor activity after multiple injuries. A dataset comprising the coagulation factor activities of 68 multiply injured adult patients was analyzed. The following trauma scores were evaluated: AIS, ISS, NISS, GCS, RTS, TRISS, RISC, and TASH score. To investigate the effect of trauma severity with respect to a single anatomic injury location, two groups according to the AIS (<3 vs. ≥3 points) were formed. Differences between these two groups were analyzed for five different body regions (head, thorax, abdomen, pelvis, extremities) using the Mann–Whitney U-test. Spearman's rank correlation coefficient rho was calculated to reveal possible relationships between trauma scores and clotting factor activities. The analysis showed clearly reduced clotting factor activities with a significant reduction of FII (83 vs. 50%; P = .021) and FV (83 vs. 46%; P = .008) for relevant (AIS ≥ 3 points) pelvic injuries. In contrast, traumatic brain injury according to the AIS head or the GCS does not appear to lead to a significant decrease in coagulation factor activities. Furthermore, the other scores studied show at best a fair correlation with coagulation factor activity. In this context, the RTS score seems to be the most suitable. Additionally, the predictive value of the TASH score, which was specifically developed to predict the need for mass transfusion, was also limited in this study. We would like to explicitly point out that this is not a criticism of the trauma scores, since they were developed in a completely different context.

Trauma induced clotting factor depletion in severely injured children: a single center observational study

Background

Coagulopathy following severe trauma contributes significantly to mortality. Impaired clotting factors have been observed in adult trauma patients, but in pediatric trauma victims their activity has not yet been investigated.

Methods

Sixteen pediatric trauma patients were evaluated according to the ISS and assigned to two cohorts. An additional control group (CO; n = 10) was formed. Routine coagulation parameters and the soluble clotting factors (F) were tested. Nonparametric data was analyzed using the Mann-Whitney U test. Results are reported as median and interquartile range.

Results

The ISS of severely (SI, n = 8) and mildly (MI, n = 8) injured children differed significantly (25 [19–28] vs. 5 [4–6]; p < 0.001). INR was elevated in the SI cohort only when compared to the CO (1.21 [1.04-1.58] vs. 0.96 [0.93-1.00]; p = 0.001). Differences between SI and MI were found for FII (67 [53-90] vs. 82 [76-114] %; p = 0.028), FV (76 [47-88] vs. 92 [82-99] %; p = 0.028), and FXIII (67 [62-87] vs. 90 [77-102] %; p = 0.021). Comparison of the SI with the CO (FII 122 [112-144] %; p < 0.001; FV 123 [100-142] %; p = 0.002; and FXIII 102 [79-115] %; p = 0.006) also revealed a reduction in the activity of these factors. Furthermore, fibrinogen (198 [80-242] vs. 296 [204-324] mg/dl; p = 0.034), FVII (71 [63-97] vs. 114 [100-152] %; p = 0.009), FIX (84 [67-103] vs. 110 [90-114] %; p = 0.043), and FX (70 [61-85] vs. 122 [96-140] %; p = 0.001) were reduced in the SI in comparison with the CO. Finally, FVIII was considerably, yet not significantly, increased in both patient cohorts (235 [91-320] % and 197 [164-238] %, respectively).

Conclusions

This study proves that children suffer a depletion of clotting factors following severe injury which basically reflects the findings for adult trauma patients. Attempts to correct the impaired clotting factor activity could be based on a specific hemostatic therapy involving administration of coagulation factors. Nevertheless, therapeutic implications need to be investigated in future studies.

Curbing Inflammation in hemorrhagic trauma: a review

Trauma is one of the world's leading causes of death within the first 40 years of life and thus a significant health problem. Trauma accounts for nearly a third of the lost years of productive life before 65 years of age and is associated with infection, hemorrhagic shock, reperfusion syndrome, and inflammation. The control of hemorrhage, coagulopathy, optimal use of blood products, balancing hypo and hyperperfusion, and hemostatic resuscitation improve survival in cases of trauma with massive hemorrhage. This review discusses inflammation in the context of trauma-associated hemorrhagic shock. When one considers the known immunomodulatory effects of traumatic injury, allogeneic blood transfusion, and the overlap between patient populations, it is surprising that so few studies have assessed their combined effects on immune function. We also discuss the relative benefits of curbing inflammation rather than attempting to prevent it.

Individual clotting factor contributions to mortality following trauma

BACKGROUND

Acute traumatic coagulopathy affects 20% to 30% of trauma patients, but the extensive collinearity of the coagulation cascade complicates attempts to clarify global clotting factor dysfunction. This study aimed to characterize phenotypes of clotting factor dysfunction and their contributions to mortality after major trauma.

METHODS

This prospective cohort study examines all adult trauma patients of the highest activation level presenting to San Francisco General Hospital between February 2005 and February 2015. Factors II, V, VII, VIII, IX, and X and protein C activity on admission and mortality status at 28 days were assessed. Predictors of 28-day mortality in univariate analysis were included in multiple logistic regression controlling for traumatic brain injury (TBI), acidosis, age, and mechanism of injury. Principal component analysis was utilized to identify phenotypic coagulation.

RESULTS

Complete coagulation factor data were available for 876 (61%) of 1,429 patients. In multiple logistic regression, factors V (odds ratio [OR], 0.86; 95% confidence interval [CI], 0.76-0.97), VIII (OR, 0.97; 95% CI, 0.95-0.99), and X (OR, 0.79; 95% CI, 0.68-0.92) and protein C (OR, 1.17; 95% CI, 1.05-1.30) significantly predicted 28-day mortality after controlling for age, base deficit, mechanism of injury, and TBI. Principal component analysis identified two significant principal components (Phenotypes 1 and 2) that accounted for 66.3% of the total variance. Phenotype 1 (factors II, VII, IX, and X and protein C abnormalities) explained 49.3% and was associated with increased injury, coagulopathy, TBI, and mortality. Phenotype 2 (factors V and VIII abnormalities) explained 17.0% and was associated with increased coagulopathy, blunt injury, and mortality. Only Phenotype 2 remained significantly associated with 28-day mortality in multiple logistic regression.

CONCLUSIONS

Principal component analysis identified two distinct phenotypes within the entirety of global clotting factor abnormalities, and these findings substantiate the crucial association of factors V and VIII on mortality following trauma. This may be the first step toward identifying unique phenotypes after injury and personalizing hemostatic resuscitation.

LEVEL OF EVIDENCE

Prognostic study, level III.

Overexpression of miR-24 Is Involved in the Formation of Hypocoagulation State after Severe Trauma by Inhibiting the Synthesis of Coagulation Factor X

BACKGROUND

Dysregulation of microRNAs may contribute to the progression of trauma-induced coagulopathy (TIC). We aimed to explore the biological function that miRNA-24-3p (miR-24) might have in coagulation factor deficiency after major trauma and TIC.

METHODS

15 healthy volunteers and 36 severe trauma patients (Injury Severity Score ≥ 16 were enrolled. TIC was determined as the initial international normalized ratio >1.5. The miR-24 expression and concentrations of factor X (FX) and factor XII in plasma were measured. In vitro study was conducted on L02 cell line.

RESULTS

The plasma miR-24 expression was significantly elevated by 3.17-fold (P = 0.043) in major trauma patients and reduced after 3 days (P < 0.01). The expression level was significantly higher in TIC than in non-TIC patients (P = 0.040). Multivariate analysis showed that the higher miR-24 expression was associated with TIC. The plasma concentration of FX in TIC patients was significantly lower than in the non-TIC ones (P = 0.030) and controls (P < 0.01). A negative correlation was observed between miR-24 and FX. miR-24 transduction significantly reduced the FX level in the supernatant of L02 cells (P = 0.030).

CONCLUSIONS

miR-24 was overexpressed in major trauma and TIC patients. The negative correlation of miR-24 with FX suggested the possibility that miR-24 might inhibit the synthesis of FX during TIC.

Pathophysiology of trauma-induced coagulopathy: disseminated intravascular coagulation with the fibrinolytic phenotype

In severe trauma patients, coagulopathy is frequently observed in the acute phase of trauma. Trauma-induced coagulopathy is coagulopathy caused by the trauma itself. The pathophysiology of trauma-induced coagulopathy consists of coagulation activation, hyperfibrino(geno)lysis, and consumption coagulopathy. These pathophysiological mechanisms are the characteristics to DIC with the fibrinolytic phenotype.

Advances in the understanding of trauma-induced coagulopathy

Ten percent of deaths worldwide are due to trauma, and it is the third most common cause of death in the United States. Despite a profound upregulation in procoagulant mechanisms, one-quarter of trauma patients present with laboratory-based evidence of trauma-induced coagulopathy (TIC), which is associated with poorer outcomes including increased mortality. The most common causes of death after trauma are hemorrhage and traumatic brain injury (TBI). The management of TIC has significant implications in both because many hemorrhagic deaths could be preventable, and TIC is associated with progression of intracranial injury after TBI. This review covers the most recent evidence and advances in our understanding of TIC, including the role of platelet dysfunction, endothelial activation, and fibrinolysis. Trauma induces a plethora of biochemical and physiologic changes, and despite numerous studies reporting differences in coagulation parameters between trauma patients and uninjured controls, it is unclear whether some of these differences may be "normal" after trauma. Comparisons between trauma patients with differing outcomes and use of animal studies have shed some light on this issue, but much of the data continue to be correlative with causative links lacking. In particular, there are little data linking the laboratory-based abnormalities with true clinically evident coagulopathic bleeding. For these reasons, TIC continues to be a significant diagnostic and therapeutic challenge.

Evaluation of Potential Clinical Surrogate Markers of a Trauma Induced Alteration of Clotting Factor Activities

Objective. The aim of this study was to identify routinely available clinical surrogate markers for potential clotting factor alterations following multiple trauma. Methods. In 68 patients admitted directly from the scene of the accident, all soluble clotting factors were analyzed and clinical data was collected prospectively. Ten healthy subjects served as control group. Results. Patients showed reduced activities of clotting factors II, V, VII, and X and calcium levels (all P < 0.0001 to 0.01). Levels of hemoglobin and base deficit correlated moderately to highly with the activities of a number of clotting factors. Nonsurvivors and patients who needed preclinical intubation or hemostatic therapy showed significantly reduced factor activities at admission. In contrast, factor VIII activity was markedly elevated after injury in general (P < 0.0001), but reduced in nonsurvivors (P < 0.05). Conclusions. Multiple trauma causes an early reduction of the activities of nearly all soluble clotting factors in general. Initial hemoglobin and, with certain qualifications, base deficit levels demonstrated a potential value in detecting those underlying clotting factor deficiencies. Nevertheless, their role as triggers of a hemostatic therapy as well as the observed response of factor VIII to multiple trauma and also its potential prognostic value needs further evaluation.

Prehospital Resuscitation of Traumatic Hemorrhagic Shock with Hypertonic Solutions Worsens Hypocoagulation and Hyperfibrinolysis

Impaired hemostasis frequently occurs after traumatic shock and resuscitation. The prehospital fluid administered can exacerbate subsequent bleeding and coagulopathy. Hypertonic solutions are recommended as first-line treatment of traumatic shock; however, their effects on coagulation are unclear. This study explores the impact of resuscitation with various hypertonic solutions on early coagulopathy after trauma. We conducted a prospective observational subgroup analysis of large clinical trial on out-of-hospital single-bolus (250 mL) hypertonic fluid resuscitation of hemorrhagic shock trauma patients (systolic blood pressure, ≤70 mmHg). Patients received 7.5% NaCl (HS), 7.5% NaCl/6% Dextran 70 (HSD), or 0.9% NaCl (normal saline [NS]) in the prehospital setting. Thirty-four patients were included: 9 HS, 8 HSD, 17 NS. Treatment with HS/HSD led to higher admission systolic blood pressure, sodium, chloride, and osmolarity, whereas lactate, base deficit, fluid requirement, and hemoglobin levels were similar in all groups. The HSD-resuscitated patients had higher admission international normalized ratio values and more hypocoagulable patients, 62% (vs. 55% HS, 47% NS; P < 0.05). Prothrombotic tissue factor was elevated in shock treated with NS but depressed in both HS and HSD groups. Fibrinolytic tissue plasminogen activator and anti-fibrinolytic plasminogen activator inhibitor type 1 were increased by shock but not thrombin-activatable fibrinolysis inhibitor. The HSD patients had the worst imbalance between procoagulation/anticoagulation and profibrinolysis/antifibrinolysis, resulting in more hypocoagulability and hyperfibrinolysis. We concluded that resuscitation with hypertonic solutions, particularly HSD, worsens hypocoagulability and hyperfibrinolysis after hemorrhagic shock in trauma through imbalances in both procoagulants and anticoagulants and both profibrinolytic and antifibrinolytic activities.

Evaluation of clotting factor activities early after severe multiple trauma and their correlation with coagulation tests and clinical data

INTRODUCTION

Traumatic injuries are amongst the leading causes of death worldwide, frequently as a result of uncontrolled hemorrhage. Critical deficiencies in clotting factors have been noted in trauma-induced coagulopathy. However, the exact underlying conditions that result in devastating coagulopathies remain unclear. The purpose of this study was to elucidate these underlying deficiencies.

METHODS

Blood samples were drawn from 45 severely injured trauma patients on their arrival at the resuscitation room, and the activities of all soluble clotting factors and routine coagulation tests were assessed. The Mann-Whitney-U-test was used to assess differences in coagulation activity between the patients and healthy controls. Furthermore, Spearman's rank correlation was used to analyze the blood work.

RESULTS

After severe trauma the levels of serum fibrinogen and calcium were significantly reduced. Furthermore, traumatized patients had a significantly increased International Normalized Ratio (INR) compared to healthy controls. The median activities of all clotting factors were reduced after severe multiple trauma, with the exception of factor VIII, which was increased. Statistically significant differences were observed for factors II (80 vs. 122 %, P < 0.0001), V (76 vs. 123 %, P < 0.0001), VII (90 vs. 114 %, P = 0.002), VIII (200 vs. 108 %, P < 0.0001), and X (86 vs. 122 %, P < 0.0001). Spearman's correlation indicated a significant negative correlation between INR on arrival with fibrinogen and levels of factors II, V, and VII, whereas Partial Thromboplastin Time was significantly negatively correlated with factor VIII (all P < 0.0001).

CONCLUSIONS

These findings suggest a general but rather moderate impairment of clotting factor activities following severe multiple trauma. In the concept of a calculated coagulation therapy, this could demand for the use of factor concentrates with higher ratios of clotting factors. Finally, the physiological importance of strongly elevated factor VIII activity remains unclear, but a possible interference with ex vivo measurements of Partial Thromboplastin Time has to be considered.

Plasma and Plasma Protein Product Transfusion: A Canadian Blood Services Centre for Innovation Symposium

Plasma obtained via whole blood donation processing or via apheresis technology can either be transfused directly to patients or pooled and fractionated into plasma protein products that are concentrates of 1 or more purified plasma protein. The evidence base supporting clinical efficacy in most of the indications for which plasma is transfused is weak, whereas high-quality evidence supports the efficacy of plasma protein products in at least some of the clinical settings in which they are used. Transfusable plasma utilization remains composed in part of applications that fall outside of clinical practice guidelines. Plasma contains all of the soluble coagulation factors and is frequently transfused in efforts to restore or reinforce patient hemostasis. The biochemical complexities of coagulation have in recent years been rationalized in newer cell-based models that supplement the cascade hypothesis. Efforts to normalize widely used clinical hemostasis screening test values by plasma transfusion are thought to be misplaced, but superior rapid tests have been slow to emerge. The advent of non-vitamin K-dependent oral anticoagulants has brought new challenges to clinical laboratories in plasma testing and to clinicians needing to reverse non-vitamin K-dependent oral anticoagulants urgently. Current plasma-related controversies include prophylactic plasma transfusion before invasive procedures, plasma vs prothrombin complex concentrates for urgent warfarin reversal, and the utility of increased ratios of plasma to red blood cell units transfused in massive transfusion protocols. The first recombinant plasma protein products to reach the clinic were recombinant hemophilia treatment products, and these donor-free equivalents to factors VIII and IX are now being supplemented with novel products whose circulatory half-lives have been increased by chemical modification or genetic fusion. Achieving optimal plasma utilization is an ongoing challenge in the interconnected worlds of transfusable plasma, plasma protein products, and recombinant and engineered replacements.

Mechanisms of trauma-induced coagulopathy

PURPOSE OF REVIEW

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.

RECENT FINDINGS

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.

SUMMARY

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.

The pathogenesis of traumatic coagulopathy

Over the last 10 years, the management of major haemorrhage in trauma patients has changed radically. This is mainly due to the recognition that many patients who are bleeding when they come in to the emergency department have an established coagulopathy before the haemodilution effects of fluid resuscitation. This has led to the use of new terminology: acute traumatic coagulopathy, acute coagulopathy of trauma shock or trauma-induced coagulopathy. The recognition of acute traumatic coagulopathy is important, because we now understand that its presence is a prognostic indicator, as it is associated with poor clinical outcome. This has driven a change in clinical management, so that the previous approach of maintaining an adequate circulating volume and oxygen carrying capacity before, as a secondary event, dealing with coagulopathy, has changed to haemostatic resuscitation as early as possible. While there is as yet no universally accepted assay or definition, many experts use prolongation of the prothrombin time to indicate that there is, indeed, a coagulopathy. Hypoxia, acidosis and hypothermia and hormonal, immunological and cytokine production, alongside consumption and blood loss, and the dilutional effects of resuscitation may occur to varying extents depending on the type of tissue damaged, the type and extent of injury, predisposing to, or amplifying, activation of coagulation, platelets, fibrinolysis. These are discussed in detail within the article.

Predictors of hypofibrinogenemia in blunt trauma patients on admission

PURPOSE

Massive bleeding usually leads to critically low levels of clotting factors, including fibrinogen. Although reduced fibrinogen levels correlate with increased mortality, predictors of hypofibrinogenemia have remained poorly understood. We investigated whether findings available on admission can be used as predictors of hypofibrinogenemia.

METHODS

We retrospectively reviewed serum fibrinogen levels tested on arrival in 290 blunt trauma patients transported to a level I trauma center during a 3-year period. The primary outcome was prehospital predictors for hypofibrinogenemia. Covariates included age, sex, prehospital fluid therapy, prehospital anatomical and physiological scores, time from injury, base excess, and lactate on arrival. All variables with values of p < 0.10 in univariate analysis were included in a multivariate logistic regression model. The relationships between the variables and the 7-day mortality rate were evaluated in a Cox proportional hazards model.

RESULTS

Patient's age [odds ratio (OR): 0.97, p < 0.001], Triage Revised Trauma Score (T-RTS) (OR: 0.81, p = 0.003), and prehospital fluid therapy (OR: 2.54, p = 0.01) were detected as independent predictors for hypofibrinogenemia in multivariate logistic regression analysis. Serum fibrinogen level [hazard ratio (HR): 0.99, p = 0.01] and T-RTS (HR: 0.77, p < 0.01) were associated with the 7-day mortality rate.

CONCLUSION

T-RTS is considered to play an important role in predicting hypofibrinogenemia and 7-day mortality in blunt trauma patients.

The challenge in management of hemorrhagic shock in trauma

Transfusion and resuscitation practices in trauma have undergone a sea change over the past decade. New understanding of transfusion physiology and experiences in military trauma over the last decade has identified key factors taken as challenges in trauma. The most important challenge remains acute traumatic coagulopathy (ATC) which sets in early after a trauma and spirals the patient into shock and continued bleeding. World wide trauma is the leading cause of mortality. More than 6 million deaths occur due to trauma out of which 20% are due to uncontrollable bleeding. Out of the hospital admissions in trauma 20% develop coagulopathy. Mortality is three to four times higher in a patient with coagulopathy and thus prevention and correction of coagulopathy is the central goal of the management of hemorrhagic shock in trauma. Damage control resuscitation (DCR), a strategy combining the techniques of permissive hypotension, hemostatic resuscitation and damage control surgery has been widely adopted as the preferred method of resuscitation in patients with haemorrhagic shock. The over-riding goals of DCR are to mitigate metabolic acidosis, hypothermia and coagulopathy, This article looks at the importance of acute traumatic coagulopathy, its etiology, diagnosis, effects and resuscitation strategies to prevent it and to see the background behind this shift.

Trauma-induced coagulopathy: from biology to therapy

Trauma is a leading cause of death and disability. Hemorrhage is the major mechanism responsible for death during the first 24 hours following trauma. One quarter of severely injured patients present in the emergency room with acute coagulopathy of trauma and shock (ACOT). The drivers of ACOT are tissue hypoperfusion, inflammation, and activation of the neurohumoral system. ACOT is a result of protein C activation with cleavage of activated factor VIII and V and inhibition of plasminogen activator inhibitor-1 (PAI-1). The resuscitation-associated coagulopathy (RAC) is secondary to a combination of acidosis, hypothermia and dilution from intravenous blood and fluid therapy. RAC may further aggravate acidosis and hypoxia resulting in a vicious cycle. This review focuses on the biology of the trauma-associated coagulopathy, and reviews current therapeutic strategies.

Traumatic coagulopathy--part 1: Pathophysiology and diagnosis

OBJECTIVE

To review the current literature in reference to the pathophysiology and diagnostic modalities available for acute traumatic coagulopathy (ATC) in relationship to traumatic hemorrhagic shock.

ETIOLOGY

Posttraumatic hemorrhage is responsible for one of the leading causes of preventable human deaths worldwide. Acute traumatic coagulopathy is an endogenous hypocoagulable condition that has been observed during the immediate (< 1 hour) posttraumatic period. Phenotypically, ATC manifests as a state of systemic hypocoagulability and hyperfibrinolysis. Although different functional mechanisms have been proposed for causing ATC, it is universally thought to be a manifestation of severe tissue injury, shock-induced hypoperfusion, systemic inflammation, and endothelial damage. Excessive activation of the thrombin-thrombomodulin activated Protein C pathway, catecholamine-induced endothelial damage as well as disseminated intravascular coagulation (DIC) with a fibrinolytic phenotype are all hypotheses that have been proposed in attempts to explain the functional mechanism of ATC.

DIAGNOSIS

An accurate and reliable test remains to be validated for ATC. Traditional coagulation assays (activated partial thromboplastin times and prothrombin times) along with platelet count and fibrinogen concentrations have been used more commonly. Viscoelastic tests (thromboelastography and rotational thromboelastometry) are currently being investigated as a more predictive modality for identifying and guiding therapy for ATC.

THERAPY

Damage control resuscitation and hemostatic resuscitation are gaining favor as the optimal resuscitative strategies for hemorrhagic shock and ATC. Antifibrinolytics may also play a role when hyperfibrinolysis is present.

PROGNOSIS

Massive hemorrhage accounts for 30-56% of prehospital posttraumatic deaths in people, with coagulopathic hemorrhage remaining one of the major causes of preventable deaths within the first 24 hours posttrauma. Ten to twenty-five percent of human trauma patients experience ATC, which has been shown to prolong hemorrhage, deter resuscitative efforts, promote sepsis, and increase mortality by at least 4-fold. Prognosis in veterinary patients is not currently known.

A principal component analysis of coagulation after trauma

BACKGROUND

Clotting factor abnormalities underlying acute traumatic coagulopathy are poorly understood, with application of traditional regression techniques confounded by colinearity. We hypothesized that principal components analysis (PCA), a pattern-finding and data reduction technique, would identify clinically predictive patterns in the complex clotting factor milieu after trauma.

METHODS

Plasma was prospectively collected from 163 critically injured trauma patients. Prothrombin; factors V, VII, VIII, IX, X; D-dimer; activated and native protein C; and antithrombin III levels were assayed and subjected to nonlinear PCA to identify principal components (PCs).

RESULTS

Of 163 patients, 19.0% were coagulopathic on admission. PCA identified 3 significant PCs, accounting for 67.5% of overall variance. PC1 identified global clotting factor depletion; PC2 the activation of protein C and fibrinolysis; and PC3 factor VII elevation and VIII depletion. PC1 score correlated with penetrating injury and injury severity, predicting coagulopathy (odds ratio [OR], 4.67; p < 0.001) and mortality (OR, 1.47; p = 0.032). PC2 score correlated with injury severity, acidosis, and shock, and significantly predicted ventilator-associated pneumonia (OR, 1.59; p = 0.008), acute lung injury (OR, 2.24; p < 0.001), multiorgan failure (OR, 1.83; p = 0.002), and mortality (OR, 1.62; p = 0.006) but was not associated with international normalized ratio (INR)-based or partial thromboplastin time (PTT)-based coagulopathy (p > 0.200). PC3 did not significantly predict outcomes.

CONCLUSION

PCA identifies distinct patterns of coagulopathy: depletion coagulopathy predicts mortality and INR/PTT elevation, while fibrinolytic coagulopathy predicts infection, end-organ failure, and mortality, without detectable differences in INR or PTT. While depletion coagulopathy is intuitive, fibrinolytic coagulopathy may be a distinct but often overlapping entity with differential effects on outcomes.

Differentiating disseminated intravascular coagulation (DIC) with the fibrinolytic phenotype from coagulopathy of trauma and acute coagulopathy of trauma-shock (COT/ACOTS)

Two concepts have been proposed for the hemostatic changes occurring early after trauma. Disseminated intravascular coagulation (DIC) with the fibrinolytic phenotype is characterized by activation of the coagulation pathways, insufficient anticoagulant mechanisms and increased fibrinolysis. Coagulopathy of trauma and acute coagulopathy of trauma-shock (COT/ACOTS) occurs as a result of increased activation of the thrombomodulin and protein C pathways, leading to the suppression of coagulation and activation of fibrinolysis. Despite the differences between these two conditions, independent consideration of COT/ACOTS from DIC with the fibrinolytic phenotype is probably incorrect. Robust diagnostic criteria based on its pathophysiology are required to establish COT/ACOTS as a new independent disease concept. In addition, the independency of its characteristics, laboratory data, time courses and prognosis from DIC should be confirmed. Confusion between two concepts may be based on studies of trauma lacking the following: (i) a clear distinction of the properties of blood between the inside and outside of vessels, (ii) a clear distinction between physiologic and pathologic hemostatic changes, (iii) attention to the time courses of the changes in hemostatic parameters, (iv) unification of the study population, and (v) recognition that massive bleeding is not synonymous with coagulation disorders. More information is needed to elucidate the pathogenesis of these two entities, DIC with the fibrinolytic phenotype and COT/ACOTS after trauma. However, available data suggest that COT/ACOTS is not a new concept but a disease entity similar to or the same as DIC with the fibrinolytic phenotype.

Critical care considerations in the management of the trauma patient following initial resuscitation

Background

Care of the polytrauma patient does not end in the operating room or resuscitation bay. The patient presenting to the intensive care unit following initial resuscitation and damage control surgery may be far from stable with ongoing hemorrhage, resuscitation needs, and injuries still requiring definitive repair. The intensive care physician must understand the respiratory, cardiovascular, metabolic, and immunologic consequences of trauma resuscitation and massive transfusion in order to evaluate and adjust the ongoing resuscitative needs of the patient and address potential complications. In this review, we address ongoing resuscitation in the intensive care unit along with potential complications in the trauma patient after initial resuscitation. Complications such as abdominal compartment syndrome, transfusion related patterns of acute lung injury and metabolic consequences subsequent to post-trauma resuscitation are presented.

Methods

A non-systematic literature search was conducted using PubMed and the Cochrane Database of Systematic Reviews up to May 2012.

Results and conclusion

Polytrauma patients with severe shock from hemorrhage and massive tissue injury present major challenges for management and resuscitation in the intensive care setting. Many of the current recommendations for “damage control resuscitation” including the use of fixed ratios in the treatment of trauma induced coagulopathy remain controversial. A lack of large, randomized, controlled trials leaves most recommendations at the level of consensus, expert opinion. Ongoing trials and improvements in monitoring and resuscitation technologies will further influence how we manage these complex and challenging patients.