not all bleeding stops: acute coagulopathy of trauma by brohi

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ACUTE TRAUMATIC COAGULOPATHY Centre for Trauma Sciences Queen Mary University of London www.c4ts.qmul.ac.uk Royal London Major Trauma Centre Barts Health NHS Trust KARIM BROHI, FRCS FRCA Professor of Trauma Sciences, QMUL

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Karim Brohi highlights the pitfalls of fluid resuscutation and the deadly spiral of coagulopathy in severe trauma.

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Page 1: Not all bleeding stops: acute coagulopathy of trauma by Brohi

ACUTE TRAUMATIC COAGULOPATHY

Centre for Trauma SciencesQueen Mary University of Londonwww.c4ts.qmul.ac.uk

Royal London Major Trauma CentreBarts Health NHS Trust

KARIM BROHI, FRCS FRCAProfessor of Trauma Sciences, QMUL

Page 2: Not all bleeding stops: acute coagulopathy of trauma by Brohi
Page 3: Not all bleeding stops: acute coagulopathy of trauma by Brohi

0%

20%

40%

60%

0 - 3 4 - 7 8 - 11 12 - 15 16 - 19 20 - 23 24 - 27 28 - 31

Mor

talit

y (%

)

PRBCs in 24 Hours

Page 4: Not all bleeding stops: acute coagulopathy of trauma by Brohi
Page 5: Not all bleeding stops: acute coagulopathy of trauma by Brohi
Page 6: Not all bleeding stops: acute coagulopathy of trauma by Brohi
Page 7: Not all bleeding stops: acute coagulopathy of trauma by Brohi

Acute Traumatic CoagulopathyATC

Page 8: Not all bleeding stops: acute coagulopathy of trauma by Brohi
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Page 10: Not all bleeding stops: acute coagulopathy of trauma by Brohi
Page 11: Not all bleeding stops: acute coagulopathy of trauma by Brohi
Page 12: Not all bleeding stops: acute coagulopathy of trauma by Brohi
Page 13: Not all bleeding stops: acute coagulopathy of trauma by Brohi
Page 14: Not all bleeding stops: acute coagulopathy of trauma by Brohi
Page 15: Not all bleeding stops: acute coagulopathy of trauma by Brohi
Page 16: Not all bleeding stops: acute coagulopathy of trauma by Brohi
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HAEMOSTATIC Resuscitation

1. Early haemorrhage control (DCS)2. Permissive hypotension3. Limit fluid infusions (dilution)4. Target coagulopathy

Page 18: Not all bleeding stops: acute coagulopathy of trauma by Brohi

Hallmarks of ATC

Page 19: Not all bleeding stops: acute coagulopathy of trauma by Brohi
Page 20: Not all bleeding stops: acute coagulopathy of trauma by Brohi

-100

-80

-60

-40

-20

0

20

40

60

80

100

0 10 20 30 40 50 60

Firm

ness

[m

m]

Time [min]

exTEM PTr Comparison

EXTEM PTR<1.2

EXTEM PTR>1.2

Page 21: Not all bleeding stops: acute coagulopathy of trauma by Brohi

ATC:CA5 < 36mm

Page 22: Not all bleeding stops: acute coagulopathy of trauma by Brohi
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Page 24: Not all bleeding stops: acute coagulopathy of trauma by Brohi
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Page 26: Not all bleeding stops: acute coagulopathy of trauma by Brohi
Page 27: Not all bleeding stops: acute coagulopathy of trauma by Brohi

CRYOSTAT

Page 28: Not all bleeding stops: acute coagulopathy of trauma by Brohi

CRYOSTAT Mortalitya

Standard: Y 7/22 : 32%Early CRYO: 3/21 : 14%

Page 29: Not all bleeding stops: acute coagulopathy of trauma by Brohi
Page 30: Not all bleeding stops: acute coagulopathy of trauma by Brohi
Page 31: Not all bleeding stops: acute coagulopathy of trauma by Brohi

6% hyperfibrinolysis100% mortality

Page 32: Not all bleeding stops: acute coagulopathy of trauma by Brohi

-100

-80

-60

-40

-20

0

20

40

60

80

100

0 10 20 30 40 50 60

Firm

ness

[m

m]

Time [min]

exTEM PTr Comparison

EXTEM PTR<1.2

EXTEM PTR>1.2

Page 33: Not all bleeding stops: acute coagulopathy of trauma by Brohi

0%

20%

40%

60%

80%

100%

≤15 16 - 50 >50

% o

f Pati

ents

% Maximum Lysis

Page 34: Not all bleeding stops: acute coagulopathy of trauma by Brohi
Page 35: Not all bleeding stops: acute coagulopathy of trauma by Brohi
Page 36: Not all bleeding stops: acute coagulopathy of trauma by Brohi

Occult FibrinolysisNormal %ML + PAP 1500-7000ng/ml

Severe Occult FibrinolysisNormal %ML + PAP >7000ng/ml

Overt Fibrinolysis%ML >15%

Page 37: Not all bleeding stops: acute coagulopathy of trauma by Brohi

0%

20%

40%

60%

Normal Occult Severe Occult Overt

% o

f Pati

ents

Hyperfibrinolysis

Page 38: Not all bleeding stops: acute coagulopathy of trauma by Brohi
Page 39: Not all bleeding stops: acute coagulopathy of trauma by Brohi
Page 40: Not all bleeding stops: acute coagulopathy of trauma by Brohi

Mechanism of ATC

Page 41: Not all bleeding stops: acute coagulopathy of trauma by Brohi

Systemic Activation of Protein C

Page 42: Not all bleeding stops: acute coagulopathy of trauma by Brohi

Activ

ated

Pro

tein

C (n

g/m

l)

Page 43: Not all bleeding stops: acute coagulopathy of trauma by Brohi
Page 44: Not all bleeding stops: acute coagulopathy of trauma by Brohi
Page 45: Not all bleeding stops: acute coagulopathy of trauma by Brohi

VIIa IXa Xa +++

+

XIIa XIa

TM TM TM TM

Thrombin

Fibrin+

platelet

Thrombin-TM

Fibrinogen

Page 46: Not all bleeding stops: acute coagulopathy of trauma by Brohi

VIIa IXa Xa

+

XIIa XIa

aPC

PC

-

Thrombin-TM

-Thrombin

Fibrin+

platelet

TM TM TM TM

Fibrinogen

Page 47: Not all bleeding stops: acute coagulopathy of trauma by Brohi
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Page 49: Not all bleeding stops: acute coagulopathy of trauma by Brohi

hyperfibrinolysis

Page 50: Not all bleeding stops: acute coagulopathy of trauma by Brohi

VIIa IXa Xa

+

XIIa XIa

aPC

PC

-

Thrombin-TM

-Thrombin

Fibrin+

platelet

TM TM TM TM

Fibrinogen

Page 51: Not all bleeding stops: acute coagulopathy of trauma by Brohi

VIIa IXa Xa

+

XIIa XIa

aPC

PC

-

Thrombin-TM

-FDPs

Plasmin

tPA

+

Thrombin

Fibrin+

platelet

+

Fibrinogen

Page 52: Not all bleeding stops: acute coagulopathy of trauma by Brohi

VIIa IXa Xa

+

XIIa XIa

aPC

PC

-

Thrombin-TM

-FDPs

Plasmin

tPA

+

Thrombin

Fibrin+

platelet

+

Fibrinogen-

Page 53: Not all bleeding stops: acute coagulopathy of trauma by Brohi

VIIa IXa Xa

+

XIIa XIa

aPC

PC

-

Thrombin-TM

-FDPs

Plasmin

tPAPAI-1

+

--

Thrombin

Fibrin+

platelet

+

Fibrinogen-

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ACUTE TRAUMATIC COAGULOPATHY

FibrinolysisFibrinogen loss

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