Not all bleeding stops: acute coagulopathy of trauma by Brohi

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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

description

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

Transcript of Not all bleeding stops: acute coagulopathy of trauma by Brohi

Page 1: Not all bleeding stops: acute coagulopathy of trauma by Brohi

ACUTE TRAUMATIC COAGULOPATHY

Centre for Trauma SciencesQueen Mary University of Londonwww.c4ts.qmul.ac.uk

Royal London Major Trauma CentreBarts Health NHS Trust

KARIM BROHI, FRCS FRCAProfessor of Trauma Sciences, QMUL

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0%

20%

40%

60%

0 - 3 4 - 7 8 - 11 12 - 15 16 - 19 20 - 23 24 - 27 28 - 31

Mor

talit

y (%

)

PRBCs in 24 Hours

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Acute Traumatic CoagulopathyATC

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HAEMOSTATIC Resuscitation

1. Early haemorrhage control (DCS)2. Permissive hypotension3. Limit fluid infusions (dilution)4. Target coagulopathy

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Hallmarks of ATC

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Firm

ness

[m

m]

Time [min]

exTEM PTr Comparison

EXTEM PTR<1.2

EXTEM PTR>1.2

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ATC:CA5 < 36mm

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CRYOSTAT

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CRYOSTAT Mortalitya

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

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6% hyperfibrinolysis100% mortality

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exTEM PTr Comparison

EXTEM PTR<1.2

EXTEM PTR>1.2

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0%

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40%

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≤15 16 - 50 >50

% o

f Pati

ents

% Maximum Lysis

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Occult FibrinolysisNormal %ML + PAP 1500-7000ng/ml

Severe Occult FibrinolysisNormal %ML + PAP >7000ng/ml

Overt Fibrinolysis%ML >15%

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0%

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Normal Occult Severe Occult Overt

% o

f Pati

ents

Hyperfibrinolysis

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Mechanism of ATC

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Systemic Activation of Protein C

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Activ

ated

Pro

tein

C (n

g/m

l)

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VIIa IXa Xa +++

+

XIIa XIa

TM TM TM TM

Thrombin

Fibrin+

platelet

Thrombin-TM

Fibrinogen

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VIIa IXa Xa

+

XIIa XIa

aPC

PC

-

Thrombin-TM

-Thrombin

Fibrin+

platelet

TM TM TM TM

Fibrinogen

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hyperfibrinolysis

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VIIa IXa Xa

+

XIIa XIa

aPC

PC

-

Thrombin-TM

-Thrombin

Fibrin+

platelet

TM TM TM TM

Fibrinogen

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VIIa IXa Xa

+

XIIa XIa

aPC

PC

-

Thrombin-TM

-FDPs

Plasmin

tPA

+

Thrombin

Fibrin+

platelet

+

Fibrinogen

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VIIa IXa Xa

+

XIIa XIa

aPC

PC

-

Thrombin-TM

-FDPs

Plasmin

tPA

+

Thrombin

Fibrin+

platelet

+

Fibrinogen-

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VIIa IXa Xa

+

XIIa XIa

aPC

PC

-

Thrombin-TM

-FDPs

Plasmin

tPAPAI-1

+

--

Thrombin

Fibrin+

platelet

+

Fibrinogen-

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ACUTE TRAUMATIC COAGULOPATHY

FibrinolysisFibrinogen loss

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