not all bleeding stops: acute coagulopathy of trauma by brohi

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