Prevention and treatment of trauma induced coagulopathy (TIC). An intended protocol from the Italian trauma update research group

Abstract

In recent years, a strong focus has been put on the need to assure early coagulation support in order to prevent and treat coagulopathy in patients with severe trauma, and to improve survival. Aggressive plasma administration with high plasma/ red blood cells ratio is increasingly used worldwide. However, plasma transfusion is associated with increased risks of multiple organ dysfunction syndrome (MODS), adult respiratory distress syndrome (ARDS) and infection, which may prolong hospital stay and the need for artificial ventilation. Moreover, in the majority of European hospitals plasma cannot be immediately available and therefore it has been reported a significant delay in coagulation support. This has lead to the proposal of using clotting factors as an alternative to plasma. However, strong evidence to define the best strategy is still missing, and the only published protocols are Institution-specific, thus depending on the local organization and the available resources. The Italian Trauma Centers Network (TUN) recently developed a treatment protocol aiming at shortening the interval before the onset of coagulation support and at reducing the use of plasma. We present this protocol-Early Coagulation Support (ECS) Protocol -and discuss its rationale. Its implications for the trauma-team workflow and hospital organization are also addressed. The ECS protocol must be considered as an integrated part of a comprehensive Damage Control Strategy. The impact of the ECS Protocol on blood products consumption, trauma mortality and morbidity as well as its financial aspects, will be strictly monitored by the TUN hospitals.

The European guideline on management of major bleeding and coagulopathy following trauma: fourth edition

“…One litre of plasma contains on average 2 g of fibrinogen. Therefore for very initial coagulation support, while waiting for the results of viscoelastic or laboratory tests, it has been proposed to administer 2 g of fibrinogen to mimic the expected 1:1 ratio corresponding to the first four units of RBC and potentially correct hypofibrinogenaemia if already present [ 385 , 404 ]. Recent experimental data show that administration of fibrinogen does not suppress endogenous fibrinogen synthesis [ 405 ].…”

“After‐hours” staffing of trauma centres and outcomes among patients presenting with acute traumatic coagulopathy

“…All patients with ATC presenting between 1 January 2006 and 31 December 2011 were included. ATC was defined as an international normalised ratio (INR) greater than 1.5 on the first sample of blood taken after presentation to hospital 11 , 15 , 16 . Patients receiving anticoagulation treatment were included.…”

Interventional Algorithms for the Control of Coagulopathic Bleeding in Surgical, Trauma, and Postpartum Settings

“… 67 , 68 These rapid POC assessment techniques are used to guide hemostatic therapy with coagulation factor concentrates as the hemostatic therapy of choice. 69 – 71 The POC tests have also provided valuable information about the hemostatic abnormalities that occur after injury and the sequence of these alterations over time. The learning acquired by this technology may help to develop treatment algorithms/protocols even when these rapid diagnostic tools are not available.…”

“…Therefore, platelet function tests should be performed to guide platelet transfusion in major patients with trauma, if platelet dysfunction is documented. 69 …”