Acute coagulopathy of trauma: Mechanism, monitoring, management

Abstract

Coagulopathy is a well-known consequence of trauma and is the most common cause of mortality in the young. However, its cause and management is still controversial. A new concept in the understanding of coagulopathy in trauma is the occurrence of Acute coagulopathy of trauma (ACoT). ACoT is associated with hypo perfusion and tissue trauma as seen in massive injury. The incidence of coagulopathy increases with injury scores and is associated with higher number of ventilator days, higher morbidity and mortality. The process of coagulation is better described by the cell based model with a central role for platelets rather than the older plasma based model. This shift in our understanding supports the theory that ACoT results from the endothelial release of thrombomodulin and activated protein C in the presence of hypoperfusion. This in turn leads on to a hyperfibrinolytic and hypocoagulable state. Viscoelastic hemostatic assays are replacing the older tests like prothrombin time in the assessment of coagulopathy. These tests are accurate, determine the need for transfusion and can be performed at the point of care. Damage control resuscitation includes newer concepts like permissive hypotension, increased use of plasma as a part of massive transfusion protocols and damage control surgery.

Keywords: Trauma; Coagulopathy; Massive transfusion; Bleeding; Thromboelastography

Core tip: Coagulopathy associated with trauma is a poorly understood and managed complication seen in severely injured patients. Acute coagulopathy of trauma, as it is currently described is attributed to trauma shock and associated tissue hypoperfusion. The traditionally attributed causes of acidosis and hypothermia contribute to a delayed form of coagulopathy, which is now considered different from early coagulopathy. Timely and appropriate use of blood and blood products along with the management of hypotension is termed damage control resuscitation. Early treatment to reverse and prevent acidosis, hypothermia and coagulopathy is the main focus.