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

1. 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

3. 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

7. Acute Traumatic Coagulopathy
ATC

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

18. Hallmarks of ATC

20. -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

21. ATC:
CA5 < 36mm

27. CRYOSTAT

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

31. 6% hyperfibrinolysis
100% mortality

32. -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

33. 0%
20%
40%
60%
80%
100%
≤15 16 - 50 >50
%ofPatients
% Maximum Lysis

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

37. 0%
20%
40%
60%
Normal Occult Severe Occult Overt
%ofPatients
Hyperfibrinolysis

40. Mechanism of ATC

41. Systemic Activation of Protein C

42. ActivatedProteinC(ng/ml)

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

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

49. hyperfibrinolysis

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

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

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

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

61. ACUTE TRAUMATIC COAGULOPATHY
Fibrinolysis
Fibrinogen loss