TRAUMA INDUCED COAGULOPATHY & MASSIVE TRANSFUSION KARIM BROHI, - PowerPoint PPT Presentation

TRAUMA INDUCED COAGULOPATHY & MASSIVE TRANSFUSION KARIM BROHI, FRCS FRCA Professor of Trauma Sciences Centre for Trauma Sciences Queen Mary University of London www.c4ts.qmul.ac.uk 1

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

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43% 8

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Acute Traumatic Coagulopathy ATC 12

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FIBTEM EXTEM Arrival 750 crystalloid 4 PRBC 2 FFP Post 4 U 4500 crystalloid 500 colloid 8 PRBC 7 FFP 1 PLT Post 8 U 2 CRYO 7500 crystalloid 1000 colloid 12 PRBC Post 12 U 8 FFP 18 PRBC 11 FFP Post 18 U 22

HAEMOSTATIC Resuscitation 1. Early haemorrhage control (DCS) 2. Permissive hypotension 3. Limit fluid infusions (dilution) 4. Target coagulopathy 23

Hallmarks of ATC 24

exTEM PTr Comparison EXTEM PTR<1.2 100 EXTEM PTR>1.2 80 60 40 Firmness [mm] 20 0 -20 -40 -60 -80 -100 0 10 20 30 40 50 60 Time [min] 25

ATC: CA5 < 36mm 26

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

60% % of Patients 40% 20% 0% Normal Occult Severe Occult Overt Hyperfibrinolysis 37

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Mechanism of ATC 39

Systemic Activation of Protein C 40

Activated Protein C (ng/ml) 41

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XIIa XIa + VIIa IXa Xa Thrombin Fibrin + + + + platelet Thrombin-TM TM TM TM TM 44

XIIa XIa + VIIa IXa Xa Thrombin Fibrin + - - platelet aPC Thrombin-TM PC TM TM TM TM 45

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hyperfibrinolysis 48

XIIa XIa + VIIa IXa Xa Thrombin Fibrin + - - platelet aPC Thrombin-TM PC TM TM TM TM 49

XIIa XIa + VIIa IXa Xa Thrombin Fibrin FDPs + - - platelet Plasmin + + tPA aPC Thrombin-TM PC 50

XIIa XIa + VIIa IXa Xa Thrombin Fibrin FDPs + - - platelet Plasmin + + - PAI-1 tPA - aPC Thrombin-TM PC 51

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ACUTE TRAUMATIC COAGULOPATHY Fibrinolysis Fibrinogen loss 55

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