Clinical Management of Severe Bleeding in Trauma Patients

2015 ◽  
pp. 89-105
Author(s):  
Giuseppe Nardi ◽  
Vanessa Agostini ◽  
Alberto Grassetto ◽  
Emiliano Cingolani ◽  
Concetta Pellegrini
Keyword(s):  
Clinical Management ◽  
Severe Bleeding ◽  
Trauma Patients

Hemostasis and Thrombosis in Trauma Patients

2015 ◽  
Vol 41 (01) ◽  
pp. 026-034 ◽  
Author(s):  
Satoshi Gando
Keyword(s):  
Wound Healing ◽  
Protein C ◽  
Activated Protein C ◽  
Fat Embolism ◽  
Whole Body ◽  
Severe Bleeding ◽  
Trauma Patients ◽  
Embolism Syndrome ◽  
Acute Coagulopathy Of Trauma ◽  
Pathological Reaction

Hemostasis and thrombosis in trauma patients consist of physiological hemostasis for wound healing and the pathological reaction of disseminated intravascular coagulation (DIC). Whole body trauma, isolated brain injury, and fat embolism syndrome, if extremely severe, can cause DIC and affect a patient's prognosis. Shock-induced hyperfibrinolysis causes DIC with the fibrinolytic phenotype, contributing to oozing-type severe bleeding. If uncontrolled, this phenotype progresses to thrombotic phenotype at the late stage of trauma, followed by microvascular thrombosis, leading to organ dysfunction. Another type of pathological hemostatic change is acute coagulopathy of trauma shock (ACOTS), which gives rise to activated protein C–mediated systemic hypocoagulation, resulting in bleeding. ACOTS occurs only in trauma associated with shock-induced hypoperfusion and there is nothing to suggest DIC in this phenomenon. This review will provide information about the recent advances in hemostasis and thrombosis in trauma and will clarify the pathogeneses of the pathological processes observed in trauma patients.

Educational Review of Predictive Value and Findings of Computed Tomography Scan in Diagnosing Bowel and Mesenteric Injuries after Blunt Trauma: Correlation with Trauma Surgery Findings in 163 Patients

2017 ◽  
Vol 68 (3) ◽  
pp. 276-285 ◽  
Author(s):  
Francesco Cinquantini ◽  
Gregorio Tugnoli ◽  
Alice Piccinini ◽  
Carlo Coniglio ◽  
Sergio Mannone ◽  
...  
Keyword(s):  
Computed Tomography ◽  
Ct Scan ◽  
Abdominal Trauma ◽  
Blunt Abdominal Trauma ◽  
Predictive Value ◽  
Gold Standard ◽  
Clinical Management ◽  
Trauma Surgery ◽  
Trauma Patients ◽  
Increased Risk

Background and Aims Laparotomy can detect bowel and mesenteric injuries in 1.2%–5% of patients following blunt abdominal trauma. Delayed diagnosis in such cases is strongly related to increased risk of ongoing sepsis, with subsequent higher morbidity and mortality. Computed tomography (CT) scanning is the gold standard in the evaluation of blunt abdominal trauma, being accurate in the diagnosis of bowel and mesenteric injuries in case of hemodynamically stable trauma patients. Aims of the present study are to 1) review the correlation between CT signs and intraoperative findings in case of bowel and mesenteric injuries following blunt abdominal trauma, analysing the correlation between radiological features and intraoperative findings from our experience on 25 trauma patients with small bowel and mesenteric injuries (SBMI); 2) identify the diagnostic specificity of those signs found at CT with practical considerations on the following clinical management; and 3) distinguish the bowel and mesenteric injuries requiring immediate surgical intervention from those amenable to initial nonoperative management. Materials and Methods Between January 1, 2008, and May 31, 2010, 163 patients required laparotomy following blunt abdominal trauma. Among them, 25 patients presented bowel or mesenteric injuries. Data were analysed retrospectively, correlating operative surgical reports with the preoperative CT findings. Results We are presenting a pictorial review of significant and frequent findings of bowel and mesenteric lesions at CT scan, confirmed intraoperatively at laparotomy. Moreover, the predictive value of CT scan for SBMI is assessed. Conclusions Multidetector CT scan is the gold standard in the assessment of intra-abdominal blunt abdominal trauma for not only parenchymal organs injuries but also detecting SBMI; in the presence of specific signs it provides an accurate assessment of hollow viscus injuries, helping the trauma surgeons to choose the correct initial clinical management.

Recombinant Factor VIIa

2007 ◽  
Vol 18 (2) ◽  
pp. 141-148
Author(s):  
Louise Rose
Keyword(s):  
Recombinant Factor Viia ◽  
Factor Viia ◽  
Case Reports ◽  
Controlled Trial ◽  
Red Blood Cell Transfusion ◽  
Severe Bleeding ◽  
Trauma Patients ◽  
Safety Issues ◽  
Uncontrolled Bleeding

Uncontrolled bleeding and coagulopathy are associated with trauma, liver failure, obstetric conditions, and a variety of surgical circumstances, resulting in increased morbidity and mortality in the critically ill. Recently, the role of recombinant factor VIIa (rFVIIa) in the management of uncontrolled bleeding has attracted interest. rFVIIa was initially developed (and licensed) for the treatment of hemophilia. Increasingly, evidence suggests rFVIIa causes cessation of bleeding, improves coagulation markers, and reduces blood product use for treatment of severe bleeding due to other causes. The majority of evidence for nonlicensed use of rFVIIa consists of case reports. Recently, the first randomized controlled trial of rFVIIa in trauma patients reported a significant reduction in red blood cell transfusion, and a trend toward reduced mortality and critical complications. As evidence builds to support the use of rFVIIa, nurses need to be aware of the administration and safety issues of this treatment.

Deviations from evidence-based clinical management guidelines increase mortality in critically injured trauma patients*

2012 ◽  
Vol 40 (3) ◽  
pp. 778-786 ◽  
Author(s):  
Todd W. Rice ◽  
Stephen Morris ◽  
Bartholomew J. Tortella ◽  
Arthur P. Wheeler ◽  
Michael C. Christensen
Keyword(s):  
Clinical Management ◽  
Evidence Based ◽  
Trauma Patients ◽  
Management Guidelines

Impact of telemedicine on diagnosis, clinical management and outcomes in rural trauma patients: A rapid review

2020 ◽  
Vol 25 (1) ◽  
pp. 31 ◽  
Author(s):  
Richard Fleet ◽  
Luc Lapointe ◽  
Marie-Helene Lavallee-Bourget ◽  
Alexia Pichard-Jolicoeur ◽  
Catherine Turgeon-Pelchat
Keyword(s):  
Clinical Management ◽  
Rapid Review ◽  
Trauma Patients

Disseminated Intravascular Coagulation

1999 ◽  
Vol 82 (08) ◽  
pp. 695-705 ◽  
Author(s):  
Evert de Jonge ◽  
Tom van der Poll ◽  
Hugo ten Cate ◽  
Marcel Levi
Keyword(s):  
Disseminated Intravascular Coagulation ◽  
Clinical Management ◽  
Multiorgan Failure ◽  
Coagulation System ◽  
Clotting Factor ◽  
Bleeding Complications ◽  
Severe Bleeding ◽  
Search Term ◽  
Variable Intensity ◽  
Intravascular Coagulation

IntroductionA quick literature search in the MEDLINE databases from 1966 to 1998 using the search term disseminated intravascular coagulation (DIC) and related key words yields an impressive 11,921 manuscripts. Most of the published literature concerns the pathophysiology of DIC, which in its main features is now well understood. Other aspects of DIC, however, particularly those related to the definition, the relevance of the syndrome, and clinical management, remain unclear. Taking an evidence-based approach to the appropriate diagnosis and treatment of patients with DIC is difficult, in view of the lack of sound clinical trials. This is probably due to the fact that DIC is a poorly-defined syndrome with a widely variable intensity, often complicating a diversity of severe disorders that are themselves related to extensive morbidity and mortality.1,2 This chapter briefly reviews the clinical setting, incidence, and relevance of DIC and current insights into the pathogenesis of DIC. It also discusses the available knowledge on the clinical management of patients with this syndrome.DIC is not a disease or a symptom but rather a syndrome, which is always secondary to an underlying disorder. The syndrome is characterized by a systemic activation of the blood coagulation system, which results in the generation and deposition of fibrin, leading to microvascular thrombi in various organs and contributing to the development of multiorgan failure. Consumption and subsequent exhaustion of coagulation proteins and platelets, due to the ongoing activation of the coagulation system, may induce severe bleeding complications, although microclot formation may occur in the absence of severe clotting factor depletion and bleeding.3 Derangement of the fibrinolytic system further contributes to intravascular clot formation (discussed later), but in some cases accelerated fibrinolysis (e.g., due to consumption of α2-antiplasmin) may cause severe bleeding. Hence, a patient with DIC can present with simultaneous thrombotic and bleeding problems, which obviously complicates treatment. Although there is no general consensus regarding the definition of DIC, the definition as put forward by Müller-Berghaus and colleagues in 1995 might be most appropriate: “Disseminated intravascular coagulation is an acquired syndrome characterized by the activation of intravascular coagulation up to intravascular fibrin formation. The process may be accompanied by secondary fibrinolysis or inhibited fibrinolysis.”4

scholarly journals Compliance with evidence-based clinical management guidelines in bleeding trauma patients

2016 ◽  
Vol 117 (5) ◽  
pp. 592-600 ◽  
Author(s):  
A. Godier ◽  
M. Bacus ◽  
E. Kipnis ◽  
B. Tavernier ◽  
A. Guidat ◽  
...  
Keyword(s):  
Clinical Management ◽  
Evidence Based ◽  
Trauma Patients ◽  
Management Guidelines

Thromboelastometry guided therapy of severe bleeding

2013 ◽  
Vol 33 (01) ◽  
pp. 51-61 ◽  
Author(s):  
M. Vorweg ◽  
A. Hanke ◽  
K. Görlinger ◽  
H. Lier
Keyword(s):  
Task Force ◽  
Coagulation Factor ◽  
Therapeutic Interventions ◽  
Screening Tests ◽  
Severe Bleeding ◽  
Trauma Patients ◽  
Coagulation Management ◽  
Transfusion Therapy ◽  
Goal Directed Therapy ◽  
Perioperative Bleeding

SummaryBoth, severe haemorrhage and blood transfusion are associated with increased morbidity and mortality. Therefore, it is of particular importance to stop perioperative bleeding as fast and as possible to avoid unnecessary transfusion. Viscoelastic test (ROTEM® or TEG®) allow for early prediction of massive transfusion and goal-directed therapy with specific haemostatic drugs, coagulation factor concentrates, and blood products. Growing consensus points out, that plasma-based coagulation screening tests like aPTT and PT are inappropriate for monitoring coagulo pathy or guide transfusion therapy. Increasing evidence of more than 5000 surgical or trauma patients points towards the beneficial effects of a thrombelastography or –metry based approach in diagnosis and goal-directed therapy of perioperative massive haemorrhage. The Essener Runde task force is a group of clinicians of various specialties (anaesthesiology, intensive care, haemostaseology, haematology, internal medicine, transfusion medicine, surgery) interested in perioperative coagulation management. The ROTEM diagnostic algorithm of the Essener Runde task force was created to standardise and simplify the interpretation of ROTEM® results in perioperative settings and to present their possible implications for therapeutic interventions in severe bleeding. To exemplify, this text mainly focuses on coagulation management in trauma.

scholarly journals An engineered activated factor V for the prevention and treatment of acute traumatic coagulopathy and bleeding in mice

2021 ◽  
Author(s):  
Bilgimol Chumappumkal Joseph ◽  
Byron Y Miyazawa ◽  
Charles Esmon ◽  
Mitchell J Cohen ◽  
Annette von Drygalski ◽  
...  
Keyword(s):  
Driving Forces ◽  
Severe Bleeding ◽  
Trauma Patients ◽  
Factor V ◽  
Activity Levels ◽  
Normal Range ◽  
Acute Traumatic Coagulopathy ◽  
Liver Laceration ◽  
Traumatic Bleeding ◽  
Traumatic Coagulopathy

Acute traumatic coagulopathy (ATC) occurs in ≈30% of trauma patients and is associated with increased mortality. Excessive generation of activated protein C (APC) and hyperfibrinolysis are believed to be driving forces for ATC. Two mouse models were used to investigate whether an engineered activated FV variant (superFVa) that is resistant to inactivation by APC and contains a stabilizing A2-A3 domain disulfide bond, is able to reduce traumatic bleeding and normalize hemostasis parameters in ATC. First, ATC was induced by the combination of trauma and shock. ATC was characterized by APTT prolongation and reductions of FV, FVIII, and fibrinogen, but not FII and FX. Administration of superFVa normalized the APTT, returned FV and FVIII clotting activity levels to their normal range, and reduced APC and thrombin-antithrombin (TAT) levels, indicating improved hemostasis. Next, a liver laceration model was used where ATC develops as the consequence of severe bleeding. SuperFVa prophylaxis prior to liver laceration reduced bleeding, prevented APTT prolongation, depletion of FV and FVIII, and excessive generation of APC. Thus, prophylactic administration of superFVa prevented the development of ATC. SuperFVa intervention started after the development of ATC stabilized bleeding, reversed the prolonged APTT, returned FV and FVIII levels to their normal range, and reduced TAT levels that were increased by ATC. In summary, superFVa prevented ATC and traumatic bleeding when administered prophylactically, and superFVa stabilized bleeding and reversed abnormal hemostasis parameters when administered while ATC was in progress. Thus, superFVa may be an attractive strategy to intercept ATC and mitigate traumatic bleeding.

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