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Early haemorrhage control and management of trauma-induced coagulopathy: the importance of goal-directed therapy

Stensballe, Jakoba,b,c; Henriksen, Hanne H.b; Johansson, Pär I.b,d,e

Current Opinion in Critical Care: December 2017 - Volume 23 - Issue 6 - p 503–510
doi: 10.1097/MCC.0000000000000466
TRAUMA: Edited by Marc Maegele
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Purpose of review The aim of this study was to discuss the recent developments in trauma-induced coagulopathy and the evolvement of goal-directed therapy.

Recent findings Mortality from major trauma continues to be a worldwide problem, and massive haemorrhage remains a major cause in 40% of potentially preventable trauma deaths. Development of trauma-induced coagulopathy challenges 25–35% of the patients further increasing trauma mortality. The pathophysiology of coagulopathy in trauma reflects at least two distinct mechanisms: Acute traumatic coagulopathy, consisting of endogenous heparinization, activation of the protein C pathway, hyperfibrinolysis and platelet dysfunction, and resuscitation associated coagulopathy. Clear fluid resuscitation with crystalloids and colloids is associated with dilutional coagulopathy and poor outcome in trauma. Haemostatic resuscitation is now the backbone of trauma resuscitation using a ratio-driven strategy aiming at 1:1:1 of red blood cells, plasma and platelets while applying goal-directed therapy early and repeatedly to control trauma-induced coagulopathy.

Summary Trauma resuscitation should focus on early goal-directed therapy with use of viscoelastic haemostatic assays while initially applying a ratio 1:1:1 driven transfusion therapy (with red blood cells, plasma and platelets) in order to sustain normal haemostasis and control further bleeding.

aDepartment of Anaesthesia, Centre of Head and Orthopaedics

bSection for Transfusion Medicine, Capital Region Blood Bank

cTrauma Centre, Centre of Head and Orthopaedics, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark

dDepartment of Surgery, Division of Acute Care Surgery, Centre for Translational Injury Research (CeTIR), University of Texas Medical School at Houston, Houston, Texas, USA

eCentre for Systems Biology, The School of Engineering and Natural Sciences, University of Iceland, Reykjavík, Iceland

Correspondence to Jakob Stensballe, MD, PhD, Department of Anaesthesia, Centre of Head and Orthopaedics, Trauma Centre, Centre of Head and Orthopaedics & Section for Transfusion Medicine, Capital Region Blood Bank, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, DK-2100 Copenhagen, Denmark. Tel: +45 2753 8687; fax: +45 35390038; e-mail: jakob.stensballe@regionh.dk

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