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!
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So let’s learn about the coagulopathy of trauma!
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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 itself
TIC. Trauma induced coagulopathy.
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This can be 2/2 acidosis, hypothermia, hemodilution or
just the trauma itself

TIC. Trauma induced coagulopathy.
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Patients w/ TIC have
longer stays
more transfusions
more days of mechanical ventilation
multiorgan dysfunction.
Also
3-4x greater mortality
are 8x more likely to die in 1st 24hrs
Most deaths 2/2 hemorrhage in the hospital occur in 1st 6 hrs.
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Also


Most deaths 2/2 hemorrhage in the hospital occur in 1st 6 hrs.
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Other factors contribute to coagulopathy
Acidosis
dysfunction of factor complexes involving negatively charged phospholipids and calcium
Hypothermia
platelet dysfunction and
enzymatic function
this would not be seen on std testing as blood rewarmed 1st
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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
with
hypotension

base deficit

injury severity
head injury
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It involves impairment of hemostasis and activation of fibrinolysis (clot breakdown).
It occurs early and risk







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Normally tissue injury
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.
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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.
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Patients w/ TIC have
activated protein C (APC)
inactive PC
soluble TM
Injury severity and shock correlate w/
APC
factors I, II, V, VIII, X
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Injury severity and shock correlate w/


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In addition to dysregulated coagulation, there is
Hyperfibrinolysis
Systemic endothelial dysfxn

inflammation 2/2
APC
Platelet dysfxn
Micro particle release and damage associated molecular patterns may also play a role.
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Micro particle release and damage associated molecular patterns may also play a role.
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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.
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A cutoff of >1.5x reference value is commonly used.
Decreased platelet count contributes to coagulopathy and poor outcomes.
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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!
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These are particularly helpful to evaluate platelet function and fibrinolysis.
In TIC, there are 2 problematic fibrinolytic phenotypes.
hyperfibrinolysis is related to TPA release w/o normal compensatory
in PAI-1 and is related to the degree of shock
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In TIC, there are 2 problematic fibrinolytic phenotypes.


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Both of these are associated with

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Other lab findings include
D-dimer
fibrinogen
factor levels
Several clinical scoring systems exist but aren’t widely used.
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Several clinical scoring systems exist but aren’t widely used.
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Tx of TIC often includes empiric or TEG based transfusion.
RBCs
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).
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RBCs

For empiric transfusion, most data support 1:1:1 ratio of plasma to RBC to platelets in patients at risk for massive transfusion (MTP).
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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.
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Multiple studies have shown improved outcomes using TEG based protocols.
In addition to transfusion, TXA is often used.
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TXA has been shown to
all cause and hemorrhage related mortality if given w/in 3 hrs of injury.
One study showed
mortality with NNT of 7 in patients requiring MTP.
Other meds used in salvage situations include Novoseven, PCC and DDAVP but
data is needed.
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One study showed

Other meds used in salvage situations include Novoseven, PCC and DDAVP but

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TIC is pretty scary.
Thank goodness for ER doctors like @jmugele that take care of these patients.
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Thank goodness for ER doctors like @jmugele that take care of these patients.
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