Transcript Coagulopathies and Trauma - Society of Trauma Nurses

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
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30-40 percent of trauma deaths are secondary
to exsanguination
Causes of Coagulopathy in Trauma
Bleeding
 Fluid Resuscitation
 Transfusions-PRBC
 Hypothermia
 Multiple injuries
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Hypothermia
Acidosis
Progressive Coagulopathy
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Multifactoral
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Dilution
Consumption of Platelets
Coagulation factor dysfunction of coagulation
system
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Partial thromboplastin time (PTT)
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Prothrombin time (PT)
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Intrinsic Pathway
Extrinsic Pathway
Thrombin time
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Common Pathway
Fresh frozen plasma
Cryoprecipitate
Epsilon-amino-caproic acid (Amicar)
DDAVP
Recombinant human factor VIIa
(Novoseven)
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)
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)
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
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
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
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
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
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
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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
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Gonzalez et al. (2007) FFP should be given
earlier to trauma patients requiring massive
transfusions. Journal of Trauma. Jan 62(1) 112119.
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Coagulopathies can be improved with strict
protocols
 1:1 PRBC to FFP
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Davis et al 2004
ICP monitor placement
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157 patients in 3 groups
 INR 0.8-1.2
 INR 1.3-1.6
 INR>1.7
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No difference in complications between the
groups and INR correction with FFP only
delayed monitor placement and treatment
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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
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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
Identify and correct any specific defect
of hemostasis
Use non-transfusional drugs whenever
possible
RBC transfusion for surgical
procedures or large blood loss