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Coagulopathies and Trauma. Cristy M. Thomas FNP-BC University of Nevada School of Medicine University Medical Center, Las Vegas NV Nevada’s Only Level 1 Adult Trauma, Level 2 Pediatric Trauma centers. Coagulopathy in Trauma. 30-40 percent of trauma deaths are secondary to exsanguination - PowerPoint PPT Presentation
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Cristy M. Thomas FNP-BCUniversity of Nevada School of
MedicineUniversity Medical Center, Las Vegas
NVNevada’s Only Level 1 Adult Trauma,
Level 2 Pediatric Trauma centers
30-40 percent of trauma deaths are secondary to exsanguination
Causes of Coagulopathy in Trauma Bleeding Fluid Resuscitation Transfusions-PRBC Hypothermia Multiple injuries
Hypothermia Acidosis Progressive Coagulopathy
Multifactoral Dilution Consumption of Platelets Coagulation factor dysfunction of coagulation
system
Partial thromboplastin time (PTT) Intrinsic Pathway
Prothrombin time (PT) Extrinsic Pathway
Thrombin time Common Pathway
Fresh frozen plasmaCryoprecipitateEpsilon-amino-caproic acid (Amicar)DDAVPRecombinant human factor VIIa (Novoseven)
SourcePlatelet concentrate (Random donor)
Each donor unit should increase platelet count ~10,000 /µlPheresis platelets (Single donor)
StorageUp to 5 days at room temperature
“Platelet trigger”Bone marrow suppressed patient (>10-20,000/µl)Bleeding/surgical patient (>50,000/µl)
Transfusion reactionsHigher incidence than in RBC transfusionsRelated to length of storage/leukocytes/RBC mismatchBacterial contamination
Platelet transfusion refractorinessAlloimmune destruction of platelets (HLA antigens)Non-immune refractoriness
Microangiopathic hemolytic anemiaCoagulopathySplenic sequestrationFever and infectionMedications (Amphotericin, vancomycin, ATG, Interferons)
Content - plasma (decreased factor V and VIII)Indications
Multiple coagulation deficiencies (liver disease, trauma)DICWarfarin reversalCoagulation deficiency (factor XI or VII)
Dose (225 ml/unit)10-15 ml/kg
NoteViral screened productABO compatible
Prepared from FFPContent
Factor VIII, von Willebrand factor, fibrinogen
IndicationsFibrinogen deficiencyUremiavon Willebrand disease
Dose (1 unit = 1 bag)1-2 units/10 kg body weight
MechanismPrevent activation plaminogen -> plasmin
Dose50mg/kg po or IV q 4 hr
UsesPrimary menorrhagiaOral bleedingBleeding in patients with thrombocytopeniaBlood loss during cardiac surgery
Side effectsGI toxicityThrombi formation
MechanismIncreased release of VWF from endothelium
Dose0.3µg/kg IV q12 hrs150mg intranasal q12hrs
UsesMost patients with von Willebrand diseaseMild hemophilia A
Side effectsFacial flushing and headacheWater retention and hyponatremia
MechanismActivates coagulation system through extrinsic pathway
Approved UseFactor VIII inhibitors in hemophiliacs
Dose: (1.2 mg/vial)90 µg/kg q 2 hr “Adjust as clinically indicated”
Cost (70 kg person) @ $1/µg~$5,000/dose or $60,000/day
Surgery or trauma with profuse bleedingConsider in patients with excessive bleeding without apparent surgical source and no response to other componentsDose: 50-100ug/kg for 1-2 dosesRisk of thrombotic complications not well defined
Anticoagulation therapy with bleeding20ug/kg with FFP if life or limb at risk; repeat if needed for bleeding
Journal of Emergency Medicine 2009 April Transfusion of Blood Products in Trauma: An
Update Massive Transfusion should be 1:1 Ratio Restrictive Transfusion Protocols Still in need of Prospective Randomized trials
to standardize protocols
Gonzalez et al. (2007) FFP should be given earlier to trauma patients requiring massive transfusions. Journal of Trauma. Jan 62(1) 112-119. Coagulopathies can be improved with strict
protocols 1:1 PRBC to FFP
Davis et al 2004 ICP monitor placement
157 patients in 3 groups INR 0.8-1.2 INR 1.3-1.6 INR>1.7
No difference in complications between the groups and INR correction with FFP only delayed monitor placement and treatment
Ilyas et al 2008 Earlier correction of INR with Factor VIIa
verses platelet transfusion 4 units vs 7 units of plasma Correction time was significantly
improved 2.4 hours vs 10 hrs
Williams et al 2008 Journal of Trauma Elderly patients classified as 50 and older INR >1.5 had a mortality rate of 22.6 %
vs 8.2% Suggestive of early monitoring and
correction or INR in anticoagulated patients 50 and older
Identify and correct any specific defect of hemostasis
Use non-transfusional drugs whenever possible
RBC transfusion for surgical procedures or large blood loss