not all bleeding stops: acute coagulopathy of trauma by brohi
DESCRIPTION
Karim Brohi highlights the pitfalls of fluid resuscutation and the deadly spiral of coagulopathy in severe trauma.TRANSCRIPT
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
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
Acute Traumatic CoagulopathyATC
HAEMOSTATIC Resuscitation
1. Early haemorrhage control (DCS)2. Permissive hypotension3. Limit fluid infusions (dilution)4. Target coagulopathy
Hallmarks of ATC
-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
ATC:CA5 < 36mm
CRYOSTAT
CRYOSTAT Mortalitya
Standard: Y 7/22 : 32%Early CRYO: 3/21 : 14%
6% hyperfibrinolysis100% mortality
-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
0%
20%
40%
60%
80%
100%
≤15 16 - 50 >50
% o
f Pati
ents
% Maximum Lysis
Occult FibrinolysisNormal %ML + PAP 1500-7000ng/ml
Severe Occult FibrinolysisNormal %ML + PAP >7000ng/ml
Overt Fibrinolysis%ML >15%
0%
20%
40%
60%
Normal Occult Severe Occult Overt
% o
f Pati
ents
Hyperfibrinolysis
Mechanism of ATC
Systemic Activation of Protein C
Activ
ated
Pro
tein
C (n
g/m
l)
VIIa IXa Xa +++
+
XIIa XIa
TM TM TM TM
Thrombin
Fibrin+
platelet
Thrombin-TM
Fibrinogen
VIIa IXa Xa
+
XIIa XIa
aPC
PC
-
Thrombin-TM
-Thrombin
Fibrin+
platelet
TM TM TM TM
Fibrinogen
hyperfibrinolysis
VIIa IXa Xa
+
XIIa XIa
aPC
PC
-
Thrombin-TM
-Thrombin
Fibrin+
platelet
TM TM TM TM
Fibrinogen
VIIa IXa Xa
+
XIIa XIa
aPC
PC
-
Thrombin-TM
-FDPs
Plasmin
tPA
+
Thrombin
Fibrin+
platelet
+
Fibrinogen
VIIa IXa Xa
+
XIIa XIa
aPC
PC
-
Thrombin-TM
-FDPs
Plasmin
tPA
+
Thrombin
Fibrin+
platelet
+
Fibrinogen-
VIIa IXa Xa
+
XIIa XIa
aPC
PC
-
Thrombin-TM
-FDPs
Plasmin
tPAPAI-1
+
--
Thrombin
Fibrin+
platelet
+
Fibrinogen-
ACUTE TRAUMATIC COAGULOPATHY
FibrinolysisFibrinogen loss