Time for my 2nd donation tweetorial and this one is for @jmugele who let me pick any topic related to the ER.

So let’s learn about the coagulopathy of trauma!

1/n

It is estimated that between 25-35% of injured trauma patients have coagulopathy on arrival to the ER!

This can be 2/2 acidosis, hypothermia, hemodilution or

just the trauma itselfhttps://abs.twimg.com/emoji/v2/... draggable="false" alt="➡️" title="Pfeil nach rechts" aria-label="Emoji: Pfeil nach rechts">

TIC. Trauma induced coagulopathy.

2/n

Patients w/ TIC have
https://abs.twimg.com/emoji/v2/... draggable="false" alt="❌" title="Kreuzzeichen" aria-label="Emoji: Kreuzzeichen">longer stays
https://abs.twimg.com/emoji/v2/... draggable="false" alt="❌" title="Kreuzzeichen" aria-label="Emoji: Kreuzzeichen">more transfusions
https://abs.twimg.com/emoji/v2/... draggable="false" alt="❌" title="Kreuzzeichen" aria-label="Emoji: Kreuzzeichen">more days of mechanical ventilation
https://abs.twimg.com/emoji/v2/... draggable="false" alt="❌" title="Kreuzzeichen" aria-label="Emoji: Kreuzzeichen"> https://abs.twimg.com/emoji/v2/... draggable="false" alt="⬆️" title="Pfeil nach oben" aria-label="Emoji: Pfeil nach oben"> multiorgan dysfunction.

Also
https://abs.twimg.com/emoji/v2/... draggable="false" alt="💀" title="Schädel" aria-label="Emoji: Schädel"> 3-4x greater mortality
https://abs.twimg.com/emoji/v2/... draggable="false" alt="💀" title="Schädel" aria-label="Emoji: Schädel"> are 8x more likely to die in 1st 24hrs

Most deaths 2/2 hemorrhage in the hospital occur in 1st 6 hrs.

3/n

Other factors contribute to coagulopathy

https://abs.twimg.com/emoji/v2/... draggable="false" alt="1️⃣" title="Tastenkappe Ziffer 1" aria-label="Emoji: Tastenkappe Ziffer 1"> Acidosis https://abs.twimg.com/emoji/v2/... draggable="false" alt="▶️" title="Nach rechts zeigendes Dreieck" aria-label="Emoji: Nach rechts zeigendes Dreieck"> dysfunction of factor complexes involving negatively charged phospholipids and calcium

https://abs.twimg.com/emoji/v2/... draggable="false" alt="2️⃣" title="Tastenkappe Ziffer 2" aria-label="Emoji: Tastenkappe Ziffer 2"> Hypothermia https://abs.twimg.com/emoji/v2/... draggable="false" alt="▶️" title="Nach rechts zeigendes Dreieck" aria-label="Emoji: Nach rechts zeigendes Dreieck"> platelet dysfunction and https://abs.twimg.com/emoji/v2/... draggable="false" alt="⬇️" title="Pfeil nach unten" aria-label="Emoji: Pfeil nach unten"> enzymatic function

https://abs.twimg.com/emoji/v2/... draggable="false" alt="*️⃣" title="Tastenkappe Sternchen" aria-label="Emoji: Tastenkappe Sternchen">this would not be seen on std testing as blood rewarmed 1st

4/n

https://abs.twimg.com/emoji/v2/... draggable="false" alt="3️⃣" title="Tastenkappe Ziffer 3" aria-label="Emoji: Tastenkappe Ziffer 3"> Resuscitation associated: alterations in hemostatic balance induced by large volumes of IV fluids or unbalanced https://abs.twimg.com/emoji/v2/... draggable="false" alt="🩸" title="Tropfen Blut" aria-label="Emoji: Tropfen Blut"> components.

https://abs.twimg.com/emoji/v2/... draggable="false" alt="4️⃣" title="Tastenkappe Ziffer 4" aria-label="Emoji: Tastenkappe Ziffer 4"> DIC. Tissue injury https://abs.twimg.com/emoji/v2/... draggable="false" alt="➡️" title="Pfeil nach rechts" aria-label="Emoji: Pfeil nach rechts"> Tissue factor exposure, activation of extrinsic pathway. Embolism of thromboplastins from sites of injury https://abs.twimg.com/emoji/v2/... draggable="false" alt="⬆️" title="Pfeil nach oben" aria-label="Emoji: Pfeil nach oben"> risk.

5/n

TIC is independent of, but compounded by those factors.

It involves impairment of hemostasis and activation of fibrinolysis (clot breakdown).

It occurs early and risk https://abs.twimg.com/emoji/v2/... draggable="false" alt="⬆️" title="Pfeil nach oben" aria-label="Emoji: Pfeil nach oben"> with
https://abs.twimg.com/emoji/v2/... draggable="false" alt="🔺" title="Nach oben zeigendes rotes Dreieck" aria-label="Emoji: Nach oben zeigendes rotes Dreieck">hypotension
https://abs.twimg.com/emoji/v2/... draggable="false" alt="🔺" title="Nach oben zeigendes rotes Dreieck" aria-label="Emoji: Nach oben zeigendes rotes Dreieck">https://abs.twimg.com/emoji/v2/... draggable="false" alt="⬆️" title="Pfeil nach oben" aria-label="Emoji: Pfeil nach oben"> base deficit
https://abs.twimg.com/emoji/v2/... draggable="false" alt="🔺" title="Nach oben zeigendes rotes Dreieck" aria-label="Emoji: Nach oben zeigendes rotes Dreieck">https://abs.twimg.com/emoji/v2/... draggable="false" alt="⬆️" title="Pfeil nach oben" aria-label="Emoji: Pfeil nach oben"> injury severity
https://abs.twimg.com/emoji/v2/... draggable="false" alt="🔺" title="Nach oben zeigendes rotes Dreieck" aria-label="Emoji: Nach oben zeigendes rotes Dreieck">head injury
6/n

Normally tissue injury https://abs.twimg.com/emoji/v2/... draggable="false" alt="➡️" title="Pfeil nach rechts" aria-label="Emoji: Pfeil nach rechts"> clot formation locally thru extrinsic(PT) pathway.

Thrombin (T) can escape injury site but systemic coagulation inhibited by circulating ATIII or by T binding to thrombomodulin(TM) on intact endothelium.

This complex (T-TM) activates protein C.

7/n

Patients w/ TIC have

https://abs.twimg.com/emoji/v2/... draggable="false" alt="⬆️" title="Pfeil nach oben" aria-label="Emoji: Pfeil nach oben">activated protein C (APC)
https://abs.twimg.com/emoji/v2/... draggable="false" alt="⬇️" title="Pfeil nach unten" aria-label="Emoji: Pfeil nach unten">inactive PC
https://abs.twimg.com/emoji/v2/... draggable="false" alt="⬆️" title="Pfeil nach oben" aria-label="Emoji: Pfeil nach oben">soluble TM

Injury severity and shock correlate w/
https://abs.twimg.com/emoji/v2/... draggable="false" alt="⬆️" title="Pfeil nach oben" aria-label="Emoji: Pfeil nach oben">APC
https://abs.twimg.com/emoji/v2/... draggable="false" alt="⬇️" title="Pfeil nach unten" aria-label="Emoji: Pfeil nach unten">factors I, II, V, VIII, X

8/n

In addition to dysregulated coagulation, there is

https://abs.twimg.com/emoji/v2/... draggable="false" alt="📍" title="Runde Reißzwecke" aria-label="Emoji: Runde Reißzwecke">Hyperfibrinolysis
https://abs.twimg.com/emoji/v2/... draggable="false" alt="📍" title="Runde Reißzwecke" aria-label="Emoji: Runde Reißzwecke">Systemic endothelial dysfxn
https://abs.twimg.com/emoji/v2/... draggable="false" alt="📍" title="Runde Reißzwecke" aria-label="Emoji: Runde Reißzwecke">https://abs.twimg.com/emoji/v2/... draggable="false" alt="⬆️" title="Pfeil nach oben" aria-label="Emoji: Pfeil nach oben"> inflammation 2/2 https://abs.twimg.com/emoji/v2/... draggable="false" alt="⬇️" title="Pfeil nach unten" aria-label="Emoji: Pfeil nach unten">APC
https://abs.twimg.com/emoji/v2/... draggable="false" alt="📍" title="Runde Reißzwecke" aria-label="Emoji: Runde Reißzwecke">Platelet dysfxn

Micro particle release and damage associated molecular patterns may also play a role.

9/n

Prolongation of PT and PTT can be seen. PT prolongation is more common and PTT more specific.

A cutoff of >1.5x reference value is commonly used.

Decreased platelet count contributes to coagulopathy and poor outcomes.

10/n

https://abs.twimg.com/emoji/v2/... draggable="false" alt="⬇️" title="Pfeil nach unten" aria-label="Emoji: Pfeil nach unten"> platelet function plays a role but dedicated testing is not typically available.

Thromboelastography (TEG) and it’s cousin ROTEM, are holistic assessments of clot formation.

Whole blood is used and provides info on clot initiation, strength AND breakdown!
11/n

These are particularly helpful to evaluate platelet function and fibrinolysis.

In TIC, there are 2 problematic fibrinolytic phenotypes.

https://abs.twimg.com/emoji/v2/... draggable="false" alt="✳️" title="Stern mit 8 Strahlen" aria-label="Emoji: Stern mit 8 Strahlen">hyperfibrinolysis is related to TPA release w/o normal compensatory https://abs.twimg.com/emoji/v2/... draggable="false" alt="⬆️" title="Pfeil nach oben" aria-label="Emoji: Pfeil nach oben"> in PAI-1 and is related to the degree of shock

12/n

https://abs.twimg.com/emoji/v2/... draggable="false" alt="✳️" title="Stern mit 8 Strahlen" aria-label="Emoji: Stern mit 8 Strahlen">finrinolytic shutdown correlates with tissue injury and is near complete inhibition of normal clot breakdown

Both of these are associated with https://abs.twimg.com/emoji/v2/... draggable="false" alt="⬆️" title="Pfeil nach oben" aria-label="Emoji: Pfeil nach oben">mortality compared to patients with normal fibrinolysis (17% in hyper, 3% in normal and 44% in shutdown!)

13/n

Other lab findings include

https://abs.twimg.com/emoji/v2/... draggable="false" alt="⬆️" title="Pfeil nach oben" aria-label="Emoji: Pfeil nach oben">D-dimer
https://abs.twimg.com/emoji/v2/... draggable="false" alt="⬇️" title="Pfeil nach unten" aria-label="Emoji: Pfeil nach unten">fibrinogen
https://abs.twimg.com/emoji/v2/... draggable="false" alt="⬇️" title="Pfeil nach unten" aria-label="Emoji: Pfeil nach unten">factor levels

Several clinical scoring systems exist but aren’t widely used.

14/n

Tx of TIC often includes empiric or TEG based transfusion.

RBCs https://abs.twimg.com/emoji/v2/... draggable="false" alt="⬆️" title="Pfeil nach oben" aria-label="Emoji: Pfeil nach oben"> perfusion and O2 carrying capacity but exacerbate coagulopathy.

For empiric transfusion, most data support 1:1:1 ratio of plasma to RBC to platelets in patients at risk for massive transfusion (MTP).

15/n

If pts not at risk for MTP, transfusions can be based on lab parameters.

Multiple studies have shown improved outcomes using TEG based protocols.

In addition to transfusion, TXA is often used.

16/n

TXA has been shown to https://abs.twimg.com/emoji/v2/... draggable="false" alt="⬇️" title="Pfeil nach unten" aria-label="Emoji: Pfeil nach unten"> all cause and hemorrhage related mortality if given w/in 3 hrs of injury.

One study showed https://abs.twimg.com/emoji/v2/... draggable="false" alt="⬇️" title="Pfeil nach unten" aria-label="Emoji: Pfeil nach unten"> mortality with NNT of 7 in patients requiring MTP.

Other meds used in salvage situations include Novoseven, PCC and DDAVP but https://abs.twimg.com/emoji/v2/... draggable="false" alt="⬆️" title="Pfeil nach oben" aria-label="Emoji: Pfeil nach oben"> data is needed.

17/n

TIC is pretty scary.

Thank goodness for ER doctors like @jmugele that take care of these patients.

18/fin