1. 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

2. 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

3. Trauma Triad • Hypothermia • Acidosis • Progressive Coagulopathy

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

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

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

7. 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)

8. 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)

9. 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

10. 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

11. Amicar • 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

12. DDVAP • 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

13. 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

14. Recombinant human factor VIIain 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: 50-100ug/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

15. 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

16. FFP Transfusion • Gonzalez et al. (2007) FFP should be given earlier to trauma patients requiring massive transfusions. Journal of Trauma. Jan 62(1) 112-119. • Coagulopathies can be improved with strict protocols • 1:1 PRBC to FFP

17. 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

18. 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

19. 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

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