Not all bleeding stops: acute coagulopathy of trauma by Brohi

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

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  • 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
  • Acute Traumatic Coagulopathy ATC
  • HAEMOSTATIC Resuscitation 1. Early haemorrhage control (DCS) 2. Permissive hypotension 3. Limit fluid infusions (dilution) 4. Target coagulopathy
  • Hallmarks of ATC
  • -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 PTR1.2
  • ATC: CA5 < 36mm
  • CRYOSTAT
  • CRYOSTAT Mortality a Standard: Y 7/22 : 32% Early CRYO: 3/21 : 14%
  • 6% hyperfibrinolysis 100% mortality
  • -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 PTR1.2
  • 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
  • Mechanism of ATC
  • Systemic Activation of Protein C
  • ActivatedProteinC(ng/ml)
  • 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
  • hyperfibrinolysis
  • 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 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