1 / 20

Coagulopathies and Trauma

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

lam
Download Presentation

Coagulopathies and Trauma

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. 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

  2. Coagulopathy in Trauma • 30-40 percent of trauma deaths are secondary to exsanguination • Causes of Coagulopathy in Trauma • Bleeding • Fluid Resuscitation • Transfusions-PRBC • Hypothermia • Multiple injuries

  3. Trauma Triad • Hypothermia • Acidosis • Progressive Coagulopathy

  4. Coagulopathic Bleeding • Multifactoral • Dilution • Consumption of Platelets • Coagulation factor dysfunction of coagulation system

  5. LABS • Partial thromboplastin time (PTT) • Intrinsic Pathway • Prothrombin time (PT) • Extrinsic Pathway • Thrombin time • Common Pathway

  6. Drug Therapy for Bleeding • Fresh frozen plasma • Cryoprecipitate • Epsilon-amino-caproic acid (Amicar) • DDAVP • Recombinant human factor VIIa (Novoseven)

  7. Platelets • Source • Platelet concentrate (Random donor) • Each donor unit should increase platelet count ~10,000 /µl • Pheresis platelets (Single donor) • Storage • Up to 5 days at room temperature • “Platelet trigger” • Bone marrow suppressed patient (>10-20,000/µl) • Bleeding/surgical patient (>50,000/µl)

  8. Platelet Transfusion Reactions • Transfusion reactions • Higher incidence than in RBC transfusions • Related to length of storage/leukocytes/RBC mismatch • Bacterial contamination • Platelet transfusion refractoriness • Alloimmune destruction of platelets (HLA antigens) • Non-immune refractoriness • Microangiopathic hemolytic anemia • Coagulopathy • Splenic sequestration • Fever and infection • Medications (Amphotericin, vancomycin, ATG, Interferons)

  9. Fresh Frozen Plasma • Content - plasma (decreased factor V and VIII) • Indications • Multiple coagulation deficiencies (liver disease, trauma) • DIC • Warfarin reversal • Coagulation deficiency (factor XI or VII) • Dose (225 ml/unit) • 10-15 ml/kg • Note • Viral screened product • ABO compatible

  10. Cryoprecipitate • Prepared from FFP • Content • Factor VIII, von Willebrand factor, fibrinogen • Indications • Fibrinogen deficiency • Uremia • von Willebrand disease • Dose (1 unit = 1 bag) • 1-2 units/10 kg body weight

  11. Amicar • Mechanism • Prevent activation plaminogen -> plasmin • Dose • 50mg/kg po or IV q 4 hr • Uses • Primary menorrhagia • Oral bleeding • Bleeding in patients with thrombocytopenia • Blood loss during cardiac surgery • Side effects • GI toxicity • Thrombi formation

  12. DDVAP • Mechanism • Increased release of VWF from endothelium • Dose • 0.3µg/kg IV q12 hrs • 150mg intranasal q12hrs • Uses • Most patients with von Willebrand disease • Mild hemophilia A • Side effects • Facial flushing and headache • Water retention and hyponatremia

  13. Recombinant human factor VIIa • Mechanism • Activates coagulation system through extrinsic pathway • Approved Use • Factor 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

  14. Recombinant human factor VIIain non-approved settings • Surgery or trauma with profuse bleeding • Consider in patients with excessive bleeding without apparent surgical source and no response to other components • Dose: 50-100ug/kg for 1-2 doses • Risk of thrombotic complications not well defined • Anticoagulation therapy with bleeding • 20ug/kg with FFP if life or limb at risk; repeat if needed for bleeding

  15. Coagulopathy and Mass Transfusions • 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

  16. FFP Transfusion • 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

  17. INR and ICP monitor placement • 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

  18. Factor VIIa and Coumadin • 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

  19. Elderly and Anticoagulation • 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

  20. Summary Identify and correct any specific defect of hemostasis Use non-transfusional drugs whenever possible RBC transfusion for surgical procedures or large blood loss

More Related