1. Trauma Induced Coagulopathy
Dr. Abdul Gafoor. M.T
MD (Anesthesiology)
ICU - ALKHOR HOSPITAL

2. Impact of TIC
 Incidence:25-35 % of Trauma cases.
 Mortality:3-4 fold higher in TI
 24 hour mortality - 8 times higher
(Brohi K et al Current Opin Crit Care 13:680-685:2007)
 Higher transfusion requirements.
 Longer intensive care unit and hospital stays.
 More days requiring mechanical ventilation.
 Greater incidence of multiorgan dysfunction.

3. Coagulation cascade

4. Feed back for hemostasis &
Hyperfibrinolysis

5. Mechanism in Trauma

6. Review of Mechanism

7. Acute Coagulopathy of Trauma
Shock (ACoTS)
 Syn:ETIC(Early Trauma Induced Coagulopathy)
 Starts in the prehospital period.
 Shock&Hypoperfusion is the cause.
 Dilution,Hypothermia,Loss of coagulation
factors not significant at this stage.
 Thrombomodulin-ProteinC pathway is activated
in hypoperfusion.
 Hypercoagulable state and risk of thrombosis
due to Protein C depletion.

8. Risk factors
 significant risk factors for life-threatening
coagulopathy
 injury severity score > 25
 systolic BP < 70mmHg
 acidosis with pH < 7.10
 hypothermia with BT < 34℃
 lethal triad
 hypothermia, metabolic acidosis,
progressive coagulopathy (Ferrara A etal Am
J surg1990:160:515)

9. Acidosis
 Marker of inadequate
tissue oxygen
utilization
 Duration of hypotension
and acidosis related to
abnormal coagulation
 Treated by improving
tissue oxygen delivery
Brohi K etal Ann of surg
2007;245:812-818

10. Dilution of clotting factors
 Resuscitation fluid
 Transfused PRBC
are plasma poor
 Factor
replacement (FFP
etc)often given
late
 Coagulation
affected when
factors are below
25%

11. Hypothermia
 Strong relationship between temperature
and survival.Less than 32°C-100%
mortality
 Mild Hypothermia-platelet function reduced
 Severe Hypothermia-Function of clotting
factors reduced
 PT,PTT performed routinely at 37°C do not
reflect the real state and misleading

12. Effect of hypoperfusion and
coagulopathy on mortality
Brohi K etal Ann of surg 2007;245:812-818

13. Changes in fibrinogen synthesis and breakdown in pigs
after haemorrhage, hypothermia, and acidosis.
Fries D , Martini W Z Br. J. Anaesth. 2010;105:116-121
© The Author [2010]. Published by Oxford University Press on behalf of the British Journal of
Anaesthesia. All rights reserved. For Permissions, please email:
journals.permissions@oxfordjournal.org
Role of Fibrinogen

14. Loss and consumption of
clotting factors
 Clotting factors lost proportionate to duration
of shock
 Loss not a problem until IV fluids are
administered
 Massive tissue factor exposure in prehospital
phase gives intense thrombosis
 Thrombosis and fibrinolysis leads to
consumptive coagulopathy
 Clot formation and quality impaired

15. The Lethal sixpack
 Tissue Injury
 Shock
 Dilution
 Hypothermia
 Acidosis
 Inflammation

16. Sequence of clotting factors
affected in bleeding
Fibrinogen F1
 Prothrombin F2
 Factor F5
 Factor F7
 Platelets
Hippala ST Anesth Analg 1995
Increased bleeding
tendency if fibrinogen
level is below1.5-2g/dl
Critical Fibrinogen
level may be reached
before need for RBC

17. Updated European guidelines
 Target Hb of 7-9 g/dl. (Grade 1C).
 Ionised calcium levels be monitored during
massive transfusion. (Grade 1C) .If low CaCl2
 FFP in a dose of 10-15ml/Kg(Grade 1B)
 Platelets to maintain a platelet count above 50 ×
10 9
/l. (Grade 1C). Above 100 × 10 9
/l in multiple
trauma or TBI (Grade 2C) .Initially4-8 platelet
concentrates or one aphaeresis pack. (Grade 2C).
Crit Care 2010;14:R52

18. Updated European guidelines
 Single haematocrit measurements not a good marker
for bleeding. (Grade 1B).
 Serum lactate and base deficit are sensitive tests to
estimate and monitor the extent of bleeding and
shock. (Grade 1B).
 PT,aPTT,INR,Fibrinogen and platelets estimation
recommended((Grade 1C)
 Thromboelastometry recommended(Grade 2C)
 Maintain Normothermia
Crit Care 2010;14:R52

19. Updated European guidelines
 If there is TEG signs of
functional fibrinogen
deficit
 If Fibrinogen levels of
1.5-2gm/dl(level grade
1 C)
 Initial dose of 3-4gms
or 50mg/Kg
 Repeated dose guided
by TEG or lab
assessment (grade 2 C)
Crit Care 2010;14:R52
Fibrinogen

20. Updated European guidelines
 Antifibrinolytic agents be considered in the
bleeding trauma patient (Grade 2C). In
established hyperfibrinolysis(Grade 1B)
 Tranexamic acid 10-15 mg/kg followed by an
infusion of 1-5 mg/kg per hour or
 ε-aminocaproic acid 100-150 mg/kg followed by
15 mg/kg/h(guided by thromboelastometry)
 Aprotinine not recommended
 Caution in renal failure
Crit Care 2010;14:R52
Antifibrinolytics

21. Updated European guidelines
 Novoseven(rFVIIa) if major bleeding in blunt trauma
persists despite standard attempts to control
bleeding and best-practice use of blood components.
(Grade 2C).
 PCC for the emergency reversal of vitamin K-
dependent oral anticoagulants. (Grade 1B).
 Desmopressin (DDAVP) considered ONLY in
refractory microvascular bleeding if the patient has
been treated with platelet-inhibiting drugs such as
aspirin. (Grade 2C).
 Antithrombin concentrates not recommended.
(Grade 1C).
Crit Care 2010;14:R52

22. Fibrinogen
 Fibrinogen as low as 2gm found to reduce post
operative blood loss upto 32%(Karlsson
etal.Thromb.Hemost 2009)
 ROTEM guided fibrinogen administration reduced
transfusion rate and postoperative blood loss
 Fibrinogen improved dilutional coagulopathy
induced by HES by increasing clot firmness
 Fibrinogen&PCC avoided PRBC transfusion in
29%patients when compared to FFP(3%)
 Fibrinogen &PCC avoided platelet transfusion in
91%patients compared to FFP(56%).
Scochi etal crit care 2011;15R83

23. Prothrombin concentrate PCC
 Initially used for immediate reversal of warfarin
 PCC available in different concentration of
ingredients in different commercial products. only
factor 9 is standardised.
 PCC contain prothrombin&factors 7,9,10
 Prothrombin is the major thrombogenic agent in
PCC.
 Combination of PCC and Fibrinogen was found to
be most effective in liver injury.

24. Tranexamic acid
 Blocks the lysine binding
site of plasmine
 CRASH 2 trial(Clinical
Randomization of an
Antifibrinolytic in
Significant Hemorrhage)
showed Tranexamic acid
reduced blood transfusion
in a dose of 20mg/Kg
 EACA (epsilon
aminocaproic acid)
another alternative.

25. Fresh Frozen Plasma
 FFP:RBC close to 1:1 ratio beneficial in
massive transfusion.In nonmassive;1:2
optimum.
 No RCTs,only retrospective data.
 7 studies favoring high ratios(1:1) regarding
mortality reduction;2 studies against.
 Time for FFP thawing, a confounding factor.
 Severity of injury another confounding
factor(received more PRBC)
 Each unit of FFP independently associated with
2.1%higher risk of MOF and 2.5%higher risk of
ARDS.

26. Recombinant Factor 7 rFVIIa
(Novoseven)
 Not a first line treatment
 In blunt trauma ,when standard therapy fails.
 In diffuse small vessel coagulopathic bleeding
 Hct>24,Platelets>50000,fibrinogen 1.5-2gm/L
and
 Acidosis,hypothrmia&hypocalcemia corrected
 First dose200mcg/Kg after 8 units PRBC
 Second and Third dose100mcg/Kg ,1 and 8
hours later.

27. Summary
 TIC starts early in trauma (ACoTS)in the pre-
hospital period and caused by shock,
hypoperfusion & Inflammation
 Aggravated by hypothermia,Acidosis,Dilution&loss
of coagulation factors.
 PT,PTT,INR,Hct unreliable in assessment.
 Thromboelastometry highly recommended
 Fibrinogen /cryoprecipitate highly recommended.
 Prothrombin concentrates(PCC) to be considered.
 Antifibrinolytics to be considered.
 Novoseven for specific indications.