Trauma-induced coagulopathy management

Background Hemorrhagic shock(HS) is one of the major causes of death and disability. Clinical investigation demonstrates that the prognosis of HS patients seems correlated with the strategies applied for resuscitation. However, treatments that can effectively improve the recovery of HS are still absent. Objective To review the treatment of HS with damage control resuscitation(DCR). Content DCR is a new integrated strategy, and has been used in a wide variety of surgeries, including trauma emergency treatment, cardiac surgery, obstetric surgery, etc. HS is commonly seen in patients with trauma-associated coagulopathy, hypothermia, and acidosis, because of the disturbed blood coagulation. DCR recommends permissive hypotension, hemostatic resuscitation, and damage control surgery in the treatment of HS. It not only improves the recovery of HS, but also helps reduce risk of shock-related complications. Trend DCR is a potential treatment for HS, while further investigations are required to optimize the procedures. Key words: Hemorrhagic shock; Damage control resuscitation; Hemostatic resuscitation

Hemorrhage remains a leading cause of preventable death in trauma, emphasizing the importance of early bleeding control. In addition to mechanical hemostasis, effective management of trauma-induced coagulopathy (TIC) plays a critical role in improving outcomes. TIC is a multifactorial condition with diverse phenotypes, involving complex pathophysiology. These variations complicate early diagnosis and targeted treatment. In the prehospital setting, phenotype-based management is not feasible; thus, empirical strategies have been adopted. Administration of tranexamic acid and prehospital whole blood transfusion have shown clinical benefit in selected trauma populations. Upon hospital arrival, fixed-ratio massive transfusion protocols and whole blood resuscitation provide broad support for coagulopathic states and have proven effective in reducing early mortality. However, these approaches may not fully account for individual variation in coagulation profiles. Viscoelastic assays allow real-time evaluation of coagulation status and offer the potential for individualized, goal-directed therapy. While some studies suggest improved outcomes with viscoelastic-guided resuscitation, evidence of clear superiority over conventional methods remains limited. Further research is needed to determine the optimal resuscitation strategy and integrate both empirical and precision-based approaches in TIC management.

This study aimed to determine whether the local administration of tranexamic acid (TXA) combined with diluted epinephrine (DEP) reduces blood loss and the need for transfusions compared with the administration of TXA alone following surgery for trochanteric femoral fractures. Hundred patients were enrolled in this study. In the target group (TXA/DEP group: n=50; 19 men and 31 women, mean age 72.5±11.1 years), the surgical sites were injected with 35 mL normal saline mixed with 3 g of TXA with 0.2 mg of DEP at a 1:200,000 dilution (TXA/DEP) immediately after musculoaponeurotic closure. In the control group (TXA group: n=50; 22 men and 28 women; mean age: 70.5±12.2 years), the surgical site was injected with 35 mL normal saline containing 3 g of TXA alone. The main outcome measures were postoperative hemoglobin (Hb) levels, hematocrit, drainage volume, and total blood loss (TBL); the secondary measures included transfusion requirements and perioperative complications. The mean Hb levels among patients in theTXA/DEP group were significantly lower than among those in the TXA group, measured on postoperative day 1 at 101.0±14.1 g/L vs. 106.9±10.5 g/L and day 3 as 104.2±8.2 g/L vs. 108.5±9.1 g/L, respectively (p<0.05). Drainage volume from the surgical site and TBL measured on postoperative day 2 were also significantly reduced in the TXA/DEP group vs. the TXA group, measured at 71.4±26.0 mL vs. 82.5±24.6 mL and 343.6±148.0 mL vs. 419.6±165.4 mL, respectively (p<0.05). Furthermore, 11 patients (22%) from the TXA group and 15 (30%) from the TXA/DEP group received blood transfusions; the mean number of transfusion events (1.2±0.4 vs. 1.9±0.7) and the amount of blood transfused (1.7±0.5 Units vs. 2.9±1.0 Units) was also markedly reduced in the TXA/DEP group (p<0.05). Two cases in the TXA/DEP group and three in the TXA group were diagnosed with deep vein thrombosis, a difference that did not reach statistical significance (p>0.05). Local administration of TXA with DEP reduced blood loss and limited the need for blood transfusions after surgery for trochanteric femoral fracture without increasing the risk of perioperative complications. Our study indicates that the local administration of TXA/DEP is safe and more effective than the administration of TXA alone in treating trochanteric femoral fractures. Level III, Therapeutic study.

Background: Hemorrhagic trauma is a major preventable cause of mortality in critically injured patients. Rapid surgical interventions are essential for hemostasis. Comprehensive critical care management before and after surgery significantly enhances the patient survival. Damage control resuscitation (DCR) concept has been adapted from the damage control method of the United States Navy, which outlines immediate temporary measures to prevent a ship from sinking, followed by the definitive repair of the ship at a dock.Current Concepts: DCR combined with damage control surgery focuses on controlling life-threatening hemorrhages and preventing trauma-induced coagulopathy. Key aspects of this strategy are: (1) Permissive hypotension (avoiding excessive fluid resuscitation to reduce re-bleeding risk), (2) restricted fluid and hemostatic resuscitation (limiting fluids and using blood products to promote coagulation), (3) use of antifibrinolytics (administering tranexamic acid to inhibit fibrinolysis and stabilize clots), (4) hypothermia prevention (maintaining normothermia to promote coagulation and mitigate acidosis), (5) calcium maintenance (maintaining normal calcium levels for proper cardiac function and coagulation), and (6) use of vasopressors (for stabilizing blood pressure and tissue perfusion). By integrating these aspects, DCR effectively controls immediate bleeding and overcomes systemic physiological challenges, thereby improving the survival of patients with severe trauma.Discussion and Conclusion: Implementation of DCR with surgical interventions as a bundle of care effectively manages hemorrhagic trauma, possibly saving the patient. Therefore, DCR is a cornerstone strategy to improve the survival of patients with hemorrhagic trauma.

Damage control: Concept and implementation

Introduction Requirement for blood transfusion in the injured paediatric civilian population is rare. Therefore, a substantial evidence base underpinning damage control resuscitation (DCR) in paediatric patients is lacking. Published outcome data originating from Iraq and Afghanistan offer a unique opportunity to study large cohorts of children who received DCR. It is hoped that by collating the data, this review will inform pre-deployment medical training and support the development of paediatric specific DCR guidelines, which can be used in all trauma environments. Methodology A comprehensive search of the literature was conducted using online databases, grey literature searching and screening of reference lists. Papers discussing blood product, crystalloid or tranexamic acid (TXA) administration in paediatric patients injured in Iraq and Afghanistan from 2001to present were included. Results Eighteen papers were included – all were retrospective studies of data from military trauma databases. Most children that received massive transfusion were male (73.4%), injured in Afghanistan (69.9%) by explosives (60.4%) with a median age of 9 years. A definition of paediatric massive transfusion of 40 ml/kg of all blood products within 24 h was developed. Massive transfusion rates were high (15.7% of children). Whole blood administration occurred in 4% of patients requiring blood transfusions. Low crystalloid volumes in combination with balanced blood product ratios were associated with improved survival, along with the use of whole blood and TXA. Conclusion The review offers insight into the paediatric population likely to require DCR and the optimal DCR strategies to be used in their management.

Despite improvements in surgical and anesthetic techniques, total joint arthroplasty (TJA) is still associated with substantial blood loss and postoperative anemia (1). A considerable portion of patients with postoperative anemia require blood transfusion, which has been shown to negatively affect the outcome of TJA and predisposes patients to development of surgical site infection and periprosthetic joint infection (2,3). Various blood conservation strategies have been developed to reduce the need for allogeneic blood transfusion in patients undergoing TJA (3). Administration of tranexamic acid (TA) is one of the most effective (4). TA is a synthetic lysine derivative drug that binds to plasminogen and prevents the interaction of plasminogen and fibrin, eventually leading to dissolution of fibrin clots (5). There is level I evidence supporting the need for allogeneic transfusion in primary total hip and total knee arthroplasties, and the efficacy of TA in particular for reducing blood loss (6,7). TA is also effective in reducing the need for blood transfusion in bilateral TJA and revision surgeries (4). Moreover, when TA is used, other blood conservation strategies are rendered unnecessary (4). The drug can be used intravenously in a weight-based manner (10-20 mg/kg), or administered 1gm intravenously at the start of surgery and 1gm intravenously at the end of surgery, or up to 3 hours after the first dose. TA can also be applied topically to the surgical site to provide hemostasis, or it can be injected intra-articularly (1g in 50 cc saline). Although oral administration of TA (25 mg/kg, maximum 2g, two hours preoperatively) has also been reported to be effective, it is not routinely used in TJA patients and intravenous and topical methods are preferred (4). Despite the proven efficacy of the use of TA in TJA, there are still some concerns about the development of venous thromboembolism (VTE) after TA is used. Since VTE following TJA is relatively rare, the majority of studies that evaluated the efficacy of TA are underpowered for evaluation of its safety. In a recent study by Poeran et al. using a large national database including 872,416 patients who had total hip or knee arthroplasty, the authors suggested that TA is effective in reducing the need for blood transfusions while not increasing the risk of VTE and renal complications (8). However, it is still advised that patients with cardiac stents and previous thromboembolic events including ischemic stroke not be administered TA. TA can also cause gastrointestinal disturbance and its dose needs to be adjusted in patients with renal impairment (5). In conclusion, administration of TA in TJA patient is a cost-effective blood conservation strategy and there is strong evidence to support the efficacy and safety of the drug in reducing blood loss and transfusion in TJA patients. Given the adverse effects of allogeneic blood transfusion on the outcome of TJA, administration of TA should be considered in patients with no contraindication for its use.

Hemorrhage after trauma remains a significant cause of preventable death. Trauma-induced coagulopathy (TIC) at the time of hospital admission is associated with an impaired outcome. Rather than a universal phenotype, TIC represents a complex hemostatic disorder, and standard coagulation tests are not designed to adequately reflect the complexity of TIC. Viscoelastic testing (VET) has gained increasing interest for the characterization of TIC because it provides a more comprehensive depiction of the coagulation process. Thus, VET has been established as a point-of-care-available hemostatic monitoring tool in many trauma centers. Damage-control resuscitation and early administration of tranexamic acid provide the basis for treating TIC. To improve survival, ratio-driven massive transfusion protocols favoring early and high-dose plasma transfusion have been implemented in many trauma centers around the world. Although plasma contains all coagulation factors and inhibitors, only high-volume plasma transfusion allows for adequate substitution of lacking coagulation proteins. However, high-volume plasma transfusion has been associated with several relevant risks. In some European trauma facilities, a more individualized hemostatic therapy concept has been implemented. The hemostatic profile of the bleeding patient is evaluated by VET. Subsequently, goal-directed hemostatic therapy is primarily based on coagulation factor concentrates such as fibrinogen concentrate or prothrombin complex concentrate. However, a clear difference in survival benefit between these two treatment strategies has not yet been shown. This concise review aims to summarize current evidence for different diagnostic and therapeutic strategies in patients with TIC.

Tranexamic acid (TXA) administered during arthroplasty intervention can prevent blood loss and blood transfusions. The purpose of the present study is to evaluate the benefit of TXA administration on blood transfusion rates in patients undergoing joint arthroplasty, and to perform cost-benefit analysis. The study population included 100 patients admitted for arthroplasty intervention between 1st June 2008 and 31st October 2008 who did not receive TXA, and 98 patients admitted between 1st June 2009 and 31st October 2009 receiving TXA during the intervention. Blood transfusion was the main outcome. Risk factors for transfusion were evaluated in logistic regression models. Costs of autologous blood donation, TXA administration, autotransfusion and homologous blood transfusion were used to perform a cost-benefit evaluation. In the multivariate adjusted analysis, high preoperative haemoglobin level and TXA administration were significantly associated with a reduced risk of transfusion. Seventy-five percent of patients not receiving TXA required at least one transfusion versus 40.8% of patients receiving TXA, with a reduction of 45.6%. The mean number of blood units transfused was reduced of 26%. The reduction in transfusions was higher in hip arthroplasty. Among patients receiving TXA, the reduction in Hb level was lower both at days 1 and 2 after the intervention. The mean saving related to TXA administration was of <euro>138 per patient. The administration of TXA during arthroplasty intervention reduces the need of transfusion among patients undertaking arthroplasty interventions and can be considered a cost-effective practice for the National Health System.

Aim: The current study aimed to evaluate the impact of administering tranexamic acid (TXA) through intravenous (IV) or intraarticular (IA) routes, in double doses, in conjunction with postoperative drain clamping (DC), on postoperative bleeding, transfusion requirements, and thromboembolic complications in patients undergoing total knee arthroplasty (TKA). Material and Methods:A retrospective review of 96 patients undergoing unilateral primary TKA for gonarthrosis between 2021 and 2022 was conducted.Patients received either double-dose IV TXA (n=52), double-dose IA TXA (n=26), or no TXA (n=18) along with postoperative DC.Various parameters were compared among groups, including preoperative and postoperative hemoglobin (Hb) levels, blood transfusion requirements, and length of hospital stay (LOS).Results: Both IV and IA double-dose TXA significantly reduced postoperative bleeding compared to no TXA administration.The need for blood transfusion was lowest in the double-dose IV TXA group.No significant differences were observed in thromboembolic complications among the groups.Length of hospital stay (LOS) was significantly shorter in the TXA groups compared to the no TXA group.Conclusions: Administration of double-dose TXA, either IV or IA and postoperative DC effectively reduced postoperative bleeding in TKA patients.Double-dose IV TXA demonstrated the lowest transfusion rates, suggesting a potential advantage in reducing transfusion requirements.Both IV and IA TXA administrations were safe and efficacious, with no significant increase in thromboembolic complications, emphasizing their overall safety profile in TKA patients.

The prehospital resuscitation of the exsanguinating patient with trauma is time and resource dependent. Rural trauma care magnifies these factors because transportation time to definitive care is increased. To address the early resuscitation needs and trauma-induced coagulopathy in the exsanguinating patient with trauma an aeromedical prehospital thawed plasma-first transfusion protocol was used. Retrospective review of trauma and flight registries between February 1, 2009, and May 31, 2011, was performed. The study population included all patients with traumatic injury transported by rotary wing aircraft who met criteria for massive transfusion protocol A total of 59 patients identified over 28 months met criteria for initiation of aeromedical initiation of prehospital blood product resuscitation. Nine patients received thawed plasma-first protocol compared with 50 controls. The prehospital plasma group was more commonly on warfarin (22 vs. 2%, p = 0.036) and had a greater degree of coagulopathy measured by international normalized ratio at baseline (2.6 vs. 1.5, p = 0.004) and trauma center arrival (1.6 vs. 1.3, p < 0.001). The prehospital plasma group had a predicted mortality nearly three times greater than controls based on Trauma and Injury Severity Score (0.24 vs. 0.66, p = 0.005). The use of prehospital plasma resuscitation led to a plasma-red blood cell ratio that more closely approximated a 1:1 resuscitation en route (1.3:1.0 vs. not applicable, p < 0.001), at 30 minutes (1.3:1.0 vs. 0.14:1.0, p < 0.001), at 6 hours (0.95:1.0 vs. 0.42:1.0, p < 0.001), and at 24 hours (1.0:1.0 vs. 0.45:1.0, p < 0.001). An equivalent amount of packed red blood cells were transfused between the groups. Despite more significant hypotension, less crystalloid was used in the prehospital thawed plasma group, through 24 hours after injury (6.3 vs. 16.4 L, p = 0.001). Use of plasma-first resuscitation in the helicopter system creates a field ready, mobile blood bank, allowing early resuscitation of the patient demonstrating need for massive transfusion. There was early treatment of trauma-induced coagulopathy. Although there was not a survival benefit demonstrated, there was resultant damage control resuscitation extending to 24 hours in the plasma-first cohort.

Damage control resuscitation (DCR) of the massively bleeding trauma patient comprises early intervention with blood products to replete intravascular volume, restore tissue oxygenation, and correct coagulopathy until surgical hemostasis can be achieved. Blood product resuscitation in the emergency department (ED), and also in the prehospital setting, must be coordinated, prompt, multifaceted, and evidence-based and should incorporate the appropriate use of laboratory tests and adjunct therapies, which facilitate DCR and damage control surgery. Hemostatic resuscitation should also address the management of the acute and delayed complications of massive transfusion including electrolyte imbalances, interstitial edema, acidosis, and hypothermia.

Coagulopathy induced by trauma or cirrhosis is a well-recognized entity. Viscoelastic testing has been used in either condition for goal-directed transfusion and detection of fibrinolysis since conventional coagulation tests do not correlate with clinical risk of bleeding. Hemostatic resuscitation may not be adequate for a trauma patient with liver disease due to complex alterations in coagulation systems and occasionally require adjuvant therapy. We report a case of trauma-induced coagulopathy presenting as severe hyperfibrinolysis in a cirrhotic patient who was refractory to hemostatic resuscitation but was rapidly corrected by the administration of tranexamic acid and recombinant Factor VIIa.

New and Off-Label Uses of Tranexamic Acid.

ObjectiveTo investigate whether intravenous combined with topical administration of tranexamic acid (TXA) is superior to intravenous administration alone in terms of blood loss, incision complications, functional recovery, and pain relief in high tibial osteotomy (HTO).MethodsClinical data of patients with knee osteoarthritis (OA) treated with unilateral HTO were retrospectively reviewed. The patients were grouped according to the TXA administration method, with 24 patients in the combined group and 21 in the solo group. In the combined group, 100 mL saline containing 1 g TXA was intravenously administered before application of a tourniquet, and 20 mL saline containing 2 g TXA was injected through a drainage tube after closure of the incision. Alternatively, 100 mL of saline containing 1 g TXA was intravenously administered before application of a tourniquet in the solo group. The blood loss and adverse events were compared between the two groups.ResultsAll patients were followed for more than half a year. The drainage volume on the first day and total blood loss on the second day after surgery in the combined and single treatment groups were 130.06 ± 29.22 and 165.35 ± 43.08 mL (P < 0.05), respectively, and 327.17 ± 64.26 and 385.45 ± 63.31 mL (P < 0.05). There were no blood transfusions in either group. One case of delayed incision healing was observed in the solo group, and no such event occurred in the combined group. There were no significant differences between the two groups in terms of the following factors: the activated partial thromboplastin time (APTT) and prothrombin time (PT); levels of fibrinogen (FIB) and D‐dimer on the second day after surgery; numbers of hospitalization days and thromboembolism events; and knee joint function and visual analog score 6 months after surgery.ConclusionIntravenous combined with topical TXA administration in HTO is superior to intravenous administration alone for reducing postoperative blood loss and drainage volume without thromboembolic complications. However, even with only intravenous TXA administration, no cases of blood transfusion and only 1 case of incision complication occurred. At the same time, the combined use of TXA did not improve the recovery of knee joint function and pain relief after HTO.