1. Interpreting the Coagulopathy of Trauma-Shock

2. Faculty Bryan A. Cotton, MD, MPH
The University of Texas Health Science Center Houston, Texas
Richard P. Dutton, MD, MBA
University of Maryland School of Medicine
R Adams Cowley Shock Trauma Center
Baltimore, Maryland
Martin A. Schreiber, MD, FACS
Oregon Health & Science University
Portland, Oregon

3. Mortality After Trauma
Retrospective review of trauma death at level I trauma center (Stewart et al, 2003)
Leading causes of death
CNS, 51%
Shock, 21%
CNS + Shock, 16%
Stewart RM, et al. J Trauma ;54:66-71.

4. Time to Death Within 12 h of arrival to ED
50% of trauma patients are dead
Within 48 h of arrival to ED
≈70% of trauma patients are dead
Early interventions can impact a patient’s life
Stewart RM, et al. J Trauma. 2003;54:66-71.

5. Coagulopathy and Mortality
Retrospective review
N=1867, 24.4% of patients significantly coagulopathic
Coagulopathy defined as:
1.5 x normal
Mortality
Overall, 19.5%
Noncoagulopathic, 10.9%
Coagulopathic, 46%
Brohi K, et al. J Trauma ;54:1127–1130.

6. Coagulopathy and Mortality
100
Normal 80
Coagulopathy 60 40
Percent Mortality 20
0-14
15-29
30-44
45-59
59-64
Injury
Severity Score
Adapted from Brohi K, et al. J Trauma ;54:1127–1130.

7. Acute Coagulopathy of Trauma

8. Acute Coagulopathy of Trauma18 17 16 15 14
Prothrombin Time(s) 13 12 11 10
2.1
7.7
Base Deficit (mEq/L)
Adapted with permission from Brohi K, et al. Ann Surg. 2007;245:

9. Shock as a Mechanism of Coagulopathy
Adapted from Hoffman M. Blood Rev. 2003;17:S1-S5.

10. Base Deficit and Protein C80 60
Thrombomodulin
(ng/mL) 40 20
2.1
7.7
Base Deficit (mEq/L)
Adapted with permission from Brohi K, et al. Ann Surg. 2007;245:

11. Base Deficit and Protein C
Activated protein C is potent anticoagulant
Activates fibrinolysis
In shock state, protein C activation→coagulopathy
Decrease in protein C concentration associated
with marked increase in mortality
Brohi K, et al. Ann Surg. 2007;245:

12. Protein C Pathway Binds protein C Produces activated protein C
Thrombomodulin increased
Binds protein C
Produces activated protein C
Inhibits factors V, VIII
Accelerates fibrinolysis

13. Rate of Heat Transfer Q=mc(T2 - T1) Heat Transfer (kcal/hr)
Rewarming Technique
Heat Transfer (kcal/hr)
Airway rewarming
8-12
Overhead radiant warmer 17
Heating blankets 20
Convective warmers
15-26
Body cavity lavage 36
Continuous arteriovenous rewarming
92-139
Cardiopulmonary bypass
710
Q=mc(T2 - T1)
Gentilello LM. In: Maull KI, et al, eds. Advances in Trauma and Critical Care. Vol 9. St Louis, MO: Mosby; 1994:39-79.

14. Effect of Hypothermia and Dilution27 25 23
Dilution 21
PT (sec) 19 17
No Dilution 15 13 28 30 32 34 36 38
Temperature (°C)
Gubler KD, et al. J Trauma ;36:

15. Changes of Plasma Fibrinogen Concentration and Platelet Count
Porcine trauma model
HCI-induced hypothermia and acidosis
pH, 7.1
Temperature, 32°C
Results:
Increased hypothermia and acidosis significantly
decreased fibrinogen concentration and
PLT counts
Martini WZ, et al. J Trauma. 2005;58:

16. Thrombin Generation
9000
Control
7500
Hypothermic
µg/L)
6000
4500
Acidotic *
[TAT] ( * *
Combined
3000 * * *
1500 * * * * * * 1 2 3 4 5 6 7
Quench Time (min)
*P.05, different from normal value at the same quench time point.
Posted with permission from Martini WZ, et al. J Trauma ;58:1002–1010. 16 16

17. Acute Coagulopathy of Trauma (ACOT)
Hemorrhage
Inflammation
Resuscitation
Shock
Other Diseases
Dilution
Acidemia
Medications
Fibrinolysis
Hypothermia
Hypothermia
Genetics
Factor Consumption
Coagulopathy
ACoTS
Hess JR, et al. J Trauma ;65:

18. Conclusions Coagulopathy following trauma is complex
Severely injured are coagulopathic immediately following injury
Most of what we do makes it worse
Early treatment should focus on stopping bleeding and correcting coagulopathy

19. Bryan A. Cotton, MD, MPH
Associate Professor of Surgery
The University of Texas
Health Science Center and
Center for Translational Injury Research
Houston, Texas

20. Has the way in which you manage the coagulopathy of trauma changed considerably over the course of your career as a surgeon?

21. Historically
Treatment delayed
Resuscitation emphasized
Currently
Arrest bleeding
Correct coagulopathy early
Downplay resuscitation
Adequate organ perfusion
Limit fluids

22. Richard P. Dutton, MD, MBA
Professor of Anesthesiology
University of Maryland School of Medicine
Attending Anesthesiologist
R Adams Cowley Shock Trauma Center
Baltimore, Maryland

23. In the upcoming year, what types of research can we expect to see disseminated in the medical literature concerning resuscitation methods and strategies for managing the coagulopathy of trauma, and what will be the focus of those papers?

24. Papers on role of recombinant factor VIIa in trauma
Results from prospective, randomized trial
expected
≈600 patients enrolled
Third or fourth largest trauma study ever conducted
Papers on plasma:red cell ratio
Match therapy to patient
Base ratio on needs of particular patient
Prospective and randomized trials

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