The Diagnosis and Treatment of Acute Traumatic Bleeding and Coagulopathy

[Hypovolaemic and haemorrhagic shock]

Hypovolemic and hemorrhagic shock are life-threatening conditions that, if untreated, rapidly lead to multi-organ failure and death. These conditions result from significant intravascular fluid or blood loss, causing critical organ hypoperfusion. The underlying pathophysiology involves complex hemodynamic, inflammatory, and coagulation disturbances that may progress to irreversible organ dysfunction. Rapid diagnosis, early hemorrhage control, and targeted hemodynamic and hemostatic therapy are crucial to improve patient outcomes. Diagnosis is based on clinical symptoms, laboratory parameters, and imaging or endoscopic assessments. The primary therapeutic approach focuses on addressing the underlying cause while implementing fluid resuscitation and vasopressor support. In hemorrhagic shock, coagulation management is of paramount importance. Essential treatment principles include maintaining normothermia, a pH above 7.2, and normocalcemia. If no contraindications exist, permissive hypotension should be applied to limit ongoing bleeding. Early goal directed administration of tranexamic acid and fibrinogen is recommended to stabilize coagulation. For patients experiencing severe hemorrhagic shock, transfusion strategies must be optimized. A hemoglobin target of 7-9g/dL is generally recommended, and in cases requiring massive transfusion, a ratio of red blood cells, plasma, and pooled platelets of 4:4:1 should be used. Additionally, patients receiving effective anticoagulation require specific reversal agents to restore hemostasis. In summary, the successful management of hypovolemic and hemorrhagic shock depends on early recognition, rapid hemorrhage control, and individualized goal directed resuscitation and hemostatic strategies.

Stop the bleed " - Prehospital bleeding control in patients with multiple and/or severe injuries - A systematic review and clinical practice guideline - A systematic review and clinical practice guideline

PURPOSE

Our aim was to develop new evidence-based and consensus-based recommendations for bleeding control in patients with multiple and/or severe injuries in the prehospital setting. This guideline topic is part of the 2022 update of the German Guideline on the Treatment of Patients with Multiple and/or Severe Injuries.

METHODS

MEDLINE and Embase were systematically searched until June 2021. Further literature reports were obtained from clinical experts. Randomised controlled trials, prospective cohort studies, and comparative registry studies were included if they compared interventions for bleeding control in the prehospital setting using manual pressure, haemostatic agents, tourniquets, pelvic stabilisation, or traction splints in patients with multiple and/or severe injuries. We considered patient-relevant clinical outcomes such as mortality and bleeding control. Transfusion requirements and haemodynamic stability were surrogate outcomes. Risk of bias was assessed using NICE 2012 checklists. The evidence was synthesised narratively, and expert consensus was used to develop recommendations and determine their strength.

RESULTS

Fifteen studies were identified. Interventions covered were pelvic binders (n = 4 studies), pressure dressings (n = 1), tourniquets (n = 6), traction splints (n = 1), haemostatic agents (n = 3), and nasal balloon catheters (n = 1). Fourteen new recommendations were developed. All achieved strong consensus.

CONCLUSION

Bleeding control is the basic objective of treatment. This can be easily justified based on empirical evidence. There is, however, a lack of reliable and high-quality studies that assess and compare methods for bleeding control in patients with multiple and/or severe injuries. The guideline provides reasonable and practical recommendations (although mostly with a low grade of recommendation) and also reveals several open research questions that can hopefully be answered when the guideline is revised again.

Four-factor Prothrombin Complex Concentrate Use for Bleeding Management in Adult Trauma

The clinical use of four-factor prothrombin complex concentrate in adult trauma patients at risk of bleeding is supported by evidence for urgent reversal of oral anticoagulants but is controversial in acquired traumatic coagulopathy.

Predictive value of systemic immune inflammation index combined with coagulation index in traumatic coagulopathy in patients with severe trauma

Background

Traumatic coagulopathy (TIC) poses a significant challenge in the management of severe trauma cases. Early identification of TIC and its risk factors is vital for initiating timely interventions. The systemic immune inflammation index (SII), a composite marker of inflammation and immune response, alongside conventional coagulation indices, may hold promise in predicting TIC. Here, this study aimed to evaluate the predictive value of combining SII with coagulation indices for TIC in severe trauma patients, with the goal of enhancing early detection and guiding prompt therapeutic strategies.

Methods

The clinical data of patients with severe trauma treated in our hospital from January 2022 to December 2022 were retrospectively selected. According to the outcome of TIC, the patients were divided into TIC group (n = 50) and non-TIC group (n = 50). The general data, SII and individual indexes of the two groups were compared, and the influencing factors of TIC were analyzed by multivariate Logistics regression. ROC analysis of SII combined with blood coagulation index to predict traumatic coagulation in patients with severe trauma.

Results

There was no significant difference in general data between the two groups. SII in TIC group was significantly higher than that in non-TIC group. neutrophil count (NEU), platelet count (PLT), lymphocyte count (LYM), activated partial thromboplastin time (APTT), prothrombin time (PT), fibrinogen (FIB) level, and D-Dimer (D-D) level in TIC group were higher than those in non-TIC group, while LYM, FIB was lower than that in non-TIC group. The logistic regression analysis showed that APTT, D-Dimer, FIB, PT, and SII were independent factors that significantly influenced TIC. The area under the curve of TIC in patients with severe trauma with SII combined with coagulation index was 0.883, and the standard error was 0.032 (95%CI:0.8195~0.9461). The best cut-off value was 0.65. The sensitivity and specificity were 80.3, 84.2 respectively.

Conclusions

SII combined with coagulation index has high predictive value for TIC in patients with severe trauma. By monitoring these indexes, we can more accurately predict the occurrence of TIC and take effective treatment measures in time.

The Intersection of Trauma and Immunity: Immune Dysfunction Following Hemorrhage

Hemorrhagic shock is caused by rapid loss of a significant blood volume, which leads to insufficient blood flow and oxygen delivery to organs and tissues, resulting in severe physiological derangements, organ failure, and death. Physiologic derangements after hemorrhage are due in a large part to the body's strong inflammatory response, which leads to severe immune dysfunction, and secondary complications such as chronic immunosuppression, increased susceptibility to infection, coagulopathy, multiple organ failure, and unregulated inflammation. Immediate management of hemorrhagic shock includes timely control of the source of bleeding, restoring intravascular volume, preferably with whole blood, and prevention of ischemia and organ failure by optimizing tissue oxygenation. However, currently, there are no clinically effective treatments available that can stabilize the immune response to hemorrhage and reinstate homeostatic conditions. In this review, we will discuss what is known about immunologic dysfunction following hemorrhage and potential therapeutic strategies.

[The golden approach to trauma. Which blood products are needed for optimization of prehospital trauma care?]

BACKGROUND

The golden hour of trauma denotes the critical first hour after severe injury where timely medical response is crucial, although scientific support for this time frame is inconsistent. This study emphasizes optimizing trauma care by tailoring treatment to the specific injury rather than focusing solely on the speed of treatment. The aim is to document the need for improvement in prehospital trauma care, particularly by the use of blood and coagulation products.

METHODS

After a pilot study, a purpose-designed online questionnaire targeted at German physicians and rescue service personnel was utilized to collect their views on general trauma care and specifically on the use of blood and coagulation products in prehospital settings. It also assessed the appropriateness of nine specific blood and coagulation products via a 5-point Likert scale. The percentages for each item were calculated for both physicians (n = 110) and rescue service personnel (n = 142) separately as well as an overall score to delineate patterns of agreement or disagreement.

RESULTS

The study reached 9837 individuals, whereby 371 initially answered the questionnaire and 252 participants from Germany were finally included in the statistical analysis. The majority of both physicians (89.1%) and rescue service personnel (90.8%) agreed on the need to improve prehospital trauma care, particularly through the use of blood and coagulation products. Specifically, 60.9% of physicians and 83.8% of rescue personnel supported the prehospital administration of these products. Red blood cell concentrates and fibrinogen were notably endorsed, with 76.2% and 67.1% approval, respectively, for their potential to enhance survival in patients with significant blood loss; however, opinions varied on other blood products.

CONCLUSION

The data demonstrated a readiness to change the trauma approach and confirmed that effective options are available. The utilization of certain products is supported by existing research, underlining the need for their practical implementation in preclinical settings. Here, the emphasis shifts from the isolated time components to the quality of care delivered in an optimized time interval. Ideally, timely and high-quality care should complement each other, leveraging all available therapeutic resources. This could lead to the development of a golden approach to trauma to optimize outcomes in trauma care.

[Anaesthesiological Management of Traumatic Brain Injury]

Traumatic brain injury (TBI) is the main cause of death in people < 45 years in industrial countries. Minimising secondary injury to the injured brain is the primary goal throughout the entire treatment. Anaesthesiologic procedures aim at the reconstitution of cerebral perfusion and homeostasis. Both TBI itself as well as accompanying injuries show effects on cardiac and pulmonary function. Time management plays a crucial role in ensuring a safe anaesthesiologic environment while minimizing unnecessary procedures. Furthermore, growing medical drug pre-treatment demands for further knowledge e.g., in antagonization of anticoagulation.

Does tranexamic acid have a positive effect on the outcome of older multiple trauma patients on antithrombotic drugs? An analysis using the TraumaRegister DGU®

Background

Acute hemorrhage is one of the most common causes of death in multiple trauma patients. Due to physiological changes, pre-existing conditions, and medication, older trauma patients are more prone to poor prognosis. Tranexamic acid (TXA) has been shown to be beneficial in multiple trauma patients with acute hemorrhage in general. The relation of tranexamic acid administration on survival in elderly trauma patients with pre-existing anticoagulation is the objective of this study. Therefore, we used the database of the TraumaRegister DGU® (TR-DGU), which documents data on severely injured trauma patients.

Methods

In this retrospective analysis, we evaluated the TR-DGU data from 16,713 primary admitted patients with multiple trauma and age &gt; =50 years from 2015 to 2019. Patients with pre-existing anticoagulation and TXA administration (996 patients, 6%), pre-existing anticoagulation without TXA administration (4,807 patients, 28.8%), without anticoagulation as premedication but TXA administration (1,957 patients, 11.7%), and without anticoagulation and TXA administration (8,953 patients, 53.6%) were identified. A regression analysis was performed to investigate the influence of pre-existing antithrombotic drugs and TXA on mortality. A propensity score was created in patients with pre-existing anticoagulation, and matching was performed for better comparability of patients with and without TXA administration.

Results

Retrospective trauma patients who underwent tranexamic acid administration were older and had a higher ISS than patients without tranexamic acid donation. Predicted mortality (according to the RISC II Score) and observed mortality were higher in the group with tranexamic acid administration. The regression analysis showed that TXA administration was associated with lower mortality rates within the first 24 h in older patients with anticoagulation as premedication. The propensity score analysis referred to higher fluid requirement, higher requirement of blood transfusion, and longer hospital stay in the group with tranexamic acid administration. There was no increase in complications. Despite higher transfusion volumes, the tranexamic acid group had a comparable all-cause mortality rate.

Conclusion

TXA administration in older trauma patients is associated with a reduced 24-h mortality rate after trauma, without increased risk of thromboembolic events. There is no relationship between tranexamic acid and overall mortality in patients with anticoagulation as premedication. Considering pre-existing anticoagulation, tranexamic acid may be recommended in elderly trauma patients with acute bleeding.

The use of vitamin K for coagulopathy in critically ill children

OBJECTIVES

Coagulopathy is associated with increased mortality in children in the intensive care unit (ICU). Recommended management of vitamin K-deficient coagulopathy is vitamin K administration. The goal of this study was to evaluate vitamin K administration for coagulopathy in critically ill children and determine a relationship between vitamin K dose and change in prothrombin time (PT) and international normalized ratio (INR).

METHODS

This retrospective cohort study reviewed electronic medical records of patients ≤17 years who received vitamin K for acute coagulopathy in the pediatric ICU from January 2013 to January 2021. Patients receiving vitamin K antagonists were excluded. Effectiveness data included change in PT/INR after vitamin K administration. Safety data included incidence of hypersensitivity or anaphylaxis.

RESULTS

A total of 310 patients (median age 6.8 years, range 22 days-17.7 years) received vitamin K. A median of three doses (range 1-8) and 0.14 mg/kg per dose (range 0.09-0.22 mg/kg) were given, most frequently intravenously (892/949, 94%). Most patients (304/310, 98%) had at least one risk factor for vitamin K deficiency. Mean PT/INR was 21.5/2.1 prior to vitamin K administration, which decreased by 4.4 (SD = 9.0, 95% CI 16.011 to 18.015, p < 0.001) and 0.5 (SD = 1.0, 95% CI 1.490 to 1.705, p < 0.001) to means of 17.0 and 1.6, respectively, after the first vitamin K dose. No linear relationship was found between vitamin K dose and change in PT/INR. No hypersensitivity or anaphylaxis occurred following vitamin K administration; 27% (84/310) of patients died.

CONCLUSIONS

Administration of vitamin K is effective and safe for the management of vitamin K-deficient coagulopathy in critically ill pediatric patients. Further study is needed to determine a relationship between vitamin K dose and change in PT/INR.

Screening of lncRNA-miRNA-mRNA Coexpression Regulatory Networks Involved in Acute Traumatic Coagulation Dysfunction Based on CTD, GeneCards, and PharmGKB Databases

Competitive endogenous RNA (ceRNA) networks play crucial roles in multiple biological processes and development of diseases. They might serve as diagnostic and prognosis markers as well as therapeutic targets. The purpose of this study was to identify a novel ceRNA network involving KCNQ1OT1, hsa-miR-24-3p, and VWF in acute traumatic coagulopathy (ATC) based on databases search. We searched the CTD, GeneCards, and PharmGKB databases for ATC-related target genes using Coagulopathy as a keyword. Upstream miRNAs and lncRNAs of the candidate target VWF were then explored using the miRWalk, microT, TargetScan, RNA22 and Tarbase, and DIANA-LncBase and Starbase databases, respectively. A KCNQ1OT1-hsa-miR-24-3p-VWF ceRNA network was constructed by R “ggalluvial” package. Interaction between KCNQ1OT1, hsa-miR-24-3p, and VWF was examined, and their expression was quantified in the peripheral blood samples from 30 ATC patients and liver tissues of ATC rat models. Forty-one ATC-related target genes were identified following data retrieval from publicly available databases, of which VWF was selected as the target and used for the subsequent analysis. KCNQ1OT1 and hsa-miR-24-3p were confirmed to be the key upstream regulatory factors of VWF. KCNQ1OT1-hsa-miR-24-3p-VWF coexpression regulatory network was constructed where KCNQ1OT1 competitively bound to hsa-miR-24-3p and attenuated its binding to VWF. Both the liver tissues of ATC rats and peripheral blood samples from ATC patients showed increased hsa-miR-24-3p expression and decreased VWF and KCNQ1OT1 expression. Collectively, we described the KCNQ1OT1-hsa-miR-24-3p-VWF ceRNA network in the development of ATC. We propose a new ceRNA that could help in the diagnosis and treatment of ATC.

Management of Coagulopathy in Bleeding Patients

Early recognition of coagulopathy is necessary for its prompt correction and successful management. Novel approaches, such as point-of-care testing (POC) and administration of coagulation factor concentrates (CFCs), aim to tailor the haemostatic therapy to each patient and thus reduce the risks of over- or under-transfusion. CFCs are an effective alternative to ratio-based transfusion therapies for the correction of different types of coagulopathies. In case of major bleeding or urgent surgery in patients treated with vitamin K antagonist anticoagulants, prothrombin complex concentrate (PCC) can effectively reverse the effects of the anticoagulant drug. Evidence for PCC effectiveness in the treatment of direct oral anticoagulants-associated bleeding is also increasing and PCC is recommended in guidelines as an alternative to specific reversal agents. In trauma-induced coagulopathy, fibrinogen concentrate is the preferred first-line treatment for hypofibrinogenaemia. Goal-directed coagulation management algorithms based on POC results provide guidance on how to adjust the treatment to the needs of the patient. When POC is not available, concentrate-based management can be guided by other parameters, such as blood gas analysis, thus providing an important alternative. Overall, tailored haemostatic therapies offer a more targeted approach to increase the concentration of coagulation factors in bleeding patients than traditional transfusion protocols.

Viscoelastic Testing and Coagulopathy of Traumatic Brain Injury

A unique coagulopathy often manifests following traumatic brain injury, leading the clinician down a difficult decision path on appropriate prophylaxis and therapy. Conventional coagulation assays—such as prothrombin time, partial thromboplastin time, and international normalized ratio—have historically been utilized to assess hemostasis and guide treatment following traumatic brain injury. However, these plasma-based assays alone often lack the sensitivity to diagnose and adequately treat coagulopathy associated with traumatic brain injury. Here, we review the whole blood coagulation assays termed viscoelastic tests and their use in traumatic brain injury. Modified viscoelastic tests with platelet function assays have helped elucidate the underlying pathophysiology and guide clinical decisions in a goal-directed fashion. Platelet dysfunction appears to underlie most coagulopathies in this patient population, particularly at the adenosine diphosphate and/or arachidonic acid receptors. Future research will focus not only on the utility of viscoelastic tests in diagnosing coagulopathy in traumatic brain injury, but also on better defining the use of these tests as evidence-based and/or precision-based tools to improve patient outcomes.

Simplified treatment algorithm for the management of trauma-induced hemorrhage without viscoelastic testing

Uncontrolled bleeding after major trauma remains a significant cause of death, with up to a third of trauma patients presenting with signs of coagulopathy at hospital admission. Rapid correction of coagulopathy is therefore vital to improve mortality rates and patient outcomes in this population. Early and repeated monitoring of coagulation parameters followed by clear protocols to correct hemostasis is the recommended standard of care for bleeding trauma patients. However, although a number of treatment algorithms are available, these are frequently complex and can rely on the use of viscoelastic testing, which is not available in all treatment centers. We therefore set out to develop a concise and pragmatic algorithm to guide treatment of bleeding trauma patients without the use of point-of-care viscoelastic testing. The algorithm we present here is based on published guidelines and research, includes recommendations regarding treatment and dosing, and is simple and clear enough for even an inexperienced physician to follow. In this way, we have demonstrated that treatment protocols can be developed and adapted to the resources available, to offer clear and relevant guidance to the entire trauma team.

Multicenter retrospective study of transcatheter arterial embolisation for life-threatening haemorrhage in patients with uncorrected bleeding diathesis

BACKGROUND

We retrospectively investigated outcomes of emergency TAE for the management of life-threatening haemorrhage in patients with uncorrected bleeding diathesis.

MATERIALS AND METHODS

This multicenter, retrospective, study, was designed to investigate the safety and efficacy of percutaneous TAE for the management of life-threatening haemorrhage in patients with uncorrected bleeding disorder at the time of embolization. All consecutive patients with uncorrected coagulation who underwent TAE for the treatment of haemorrhage, between January 1st and December 31th 2019 in three European centers were included. Inclusion criteria were thrombocytopenia (platelet count < 50,000/mL) and/or International Normalized Ratio (INR) ≥2.0, and/or activated partial thromboplastin time (aPTT) > 45 s, and/or a pre-existing underlying blood-clotting disorder such as factor VIII, Von Willebrand disease, hepatic cirrhosis with abnormal liver function tests. Primary outcome measures were technical success, rebleeding rate and clinical success. Secondary outcome measures included patients' 30-day survival rate, and procedure-related complications.

RESULTS

In total, 134 patients underwent TAE for bleeding control. A subgroup of 17 patients with 18 procedures [11 female, mean age 70.5 ± 15 years] which represent 12.7% of the total number of patients, presented with pathological coagulation parameters at the time of TAE (haemophilia n = 3, thrombocytopenia n = 1, cirrhosis n = 5, anticoagulants n = 7, secondary to bleeding n = 1) and were analyzed. Technical success was 100%, as in all procedures the bleeding site was detected and successfully embolised. Clinical success was 100%, as none of the patients died of bleeding during hospitalization, nor was surgically treated for bleeding relapse. Only one rebleeding case was noted (5.9%) that was successfully treated with a second TAE. No procedure-related complications were noted. According to Kaplan-Meier analysis the estimated 30-day survival rate was 84.2%.

CONCLUSION

TAE in selected patients with uncorrected bleeding diathesis should be considered as a suitable individualized management approach. Emergency TAE for life threatening haemorrhage in patients with coagulation cascade disorders should be used as an aid in realistic clinical decision making.