Not all bleeding stops: acute coagulopathy of trauma by Brohi

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SMACC Conference

Karim Brohi highlights the pitfalls of fluid resuscutation and the deadly spiral of coagulopathy in severe trauma.

Santé & Médecine

ACUTE TRAUMATIC COAGULOPATHY
Centre for Trauma Sciences
Queen Mary University of London
www.c4ts.qmul.ac.uk
Royal London Major Trauma Centre
Barts Health NHS Trust
KARIM BROHI, FRCS FRCA
Professor of Trauma Sciences, QMUL

0%
20%
40%
60%
0 - 3 4 - 7 8 - 11 12 - 15 16 - 19 20 - 23 24 - 27 28 - 31
Mortality(%)
PRBCs in 24 Hours

HAEMOSTATIC Resuscitation
1. Early haemorrhage control (DCS)
2. Permissive hypotension
3. Limit fluid infusions (dilution)
4. Target coagulopathy

-100
-80
-60
-40
-20
0
20
40
60
80
100
0 10 20 30 40 50 60
Firmness[mm]
Time [min]
exTEM PTr Comparison
EXTEM PTR<1.2
EXTEM PTR>1.2

CRYOSTAT Mortality
a
Standard: Y 7/22 : 32%
Early CRYO: 3/21 : 14%

0%
20%
40%
60%
80%
100%
≤15 16 - 50 >50
%ofPatients
% Maximum Lysis

Occult Fibrinolysis
Normal %ML + PAP 1500-7000ng/ml
Severe Occult Fibrinolysis
Normal %ML + PAP >7000ng/ml
Overt Fibrinolysis
%ML >15%

0%
20%
40%
60%
Normal Occult Severe Occult Overt
%ofPatients
Hyperfibrinolysis

VIIa IXa Xa
+++
+
XIIa XIa
TM TM TM TM
Thrombin Fibrin
+
platelet
Thrombin-TM
Fibrinogen

VIIa IXa Xa
+
XIIa XIa
aPC
PC
-
Thrombin-TM
-
Thrombin Fibrin
+
platelet
TM TM TM TM
Fibrinogen

VIIa IXa Xa
+
XIIa XIa
aPC
PC
-
Thrombin-TM
-
FDPs
Plasmin
tPA
+
Thrombin Fibrin
+
platelet
+
Fibrinogen

VIIa IXa Xa
+
XIIa XIa
aPC
PC
-
Thrombin-TM
-
FDPs
Plasmin
tPAPAI-1
+
-
-
Thrombin Fibrin
+
platelet
+
Fibrinogen
-

ACUTE TRAUMATIC COAGULOPATHY
Fibrinolysis
Fibrinogen loss

Not all bleeding stops: acute coagulopathy of trauma by Brohi

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