COAGULOPATHIES AND TRAUMA Cristy M Thomas FNPBC University

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 Causes of Coagulopathy in Trauma Bleeding Fluid Resuscitation Transfusions-PRBC Hypothermia Multiple injuries

Trauma Triad Hypothermia Acidosis Progressive Coagulopathy

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

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

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

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)

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)

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

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

Amicar Mechanism Prevent activation plaminogen -> plasmin Dose 50 mg/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

DDVAP Mechanism Increased release of VWF from endothelium Dose 0. 3µg/kg IV q 12 hrs 150 mg intranasal q 12 hrs Uses Most patients with von Willebrand disease Mild hemophilia A Side effects Facial flushing and headache Water retention and hyponatremia

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

Recombinant human factor VIIa in 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 -100 ug/kg for 1 -2 doses Risk of thrombotic complications not well defined Anticoagulation therapy with bleeding 20 ug/kg with FFP if life or limb at risk; repeat if needed for bleeding

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

FFP Transfusion Gonzalez et al. (2007) FFP should be given earlier to trauma patients requiring massive transfusions. Journal of Trauma. Jan 62(1) 112119. Coagulopathies can be improved with strict protocols 1: 1 PRBC to FFP

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

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

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

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