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Management of Coagulopathy in the Patients With Multiple Injuries: Results From an International Survey of Clinical Practice

Hoyt, David B. MD, FACS; Dutton, Richard P. MD, MBA; Hauser, Carl J. MD, FACS, FCCM; Hess, John R. MD, MPH, FACP, FAAAS; Holcomb, John B. MD, FACS; Kluger, Yoram MD; Mackway-Jones, Kevin MD, FRCP, FRCS, FCEM; Parr, Michael J. MB, BS, FRCP, FRCA, FANZCA, FJFICM; Rizoli, Sandro B. MD, PhD, FRCSC; Yukioka, Tetsuo MD; Bouillon, Bertil MD

The Journal of Trauma: Injury, Infection, and Critical Care: October 2008 - Volume 65 - Issue 4 - p 755-765
doi: 10.1097/TA.0b013e318185fa9f
Original Article

Background: Bleeding is one of the leading causes of preventable death after traumatic injury. Trauma-associated coagulopathy complicates the control of bleeding. The published approaches on the management of this coagulopathy differ significantly.

Methods: A qualitative international survey of clinical practice among senior physicians responsible for the treatment of patients with multiple injuries (Injury Severity Score ≥16) was conducted to document common practices, highlight the variabilities, and profile the rationale behind existing clinical practices around the world.

Results: Survey results are based on 80 (32%) completed returns, representing 25 countries with 93% of respondents employed by trauma centers and a mean of 20 years clinical experience. There are regional differences in the clinical specialty of physicians responsible for trauma management decisions. Blood loss, temperature, pH, platelets, prothrombin time/INR/activated partial thromboplastin time, and overall clinical assessment, were the most common criteria used to assess coagulopathy. Forty-five percent of respondents claimed to follow a massive transfusion protocol in their institution, 19% reported inconsistent protocol use and 34% do not use a protocol. The management of hypothermia, acidosis, blood products, and adjuvant therapy showed regional as well as institutional variability, and surprisingly few massive transfusion protocols specifically address these issues.

Conclusions: The results of this survey may serve to draw attention to the need for a common definition of coagulopathy and standardized clinical protocols to ensure optimal patient care.

From the Department of Surgery (D.B.H.), University of California, Irvine, California; Shock Trauma Center (R.P.D.), University of Maryland School of Medicine, Baltimore, Maryland; Department of Surgery (C.J.H.), Beth Israel Deaconess Medical Center, Boston, Maryland; Department of Pathology (J.R.H.), University of Maryland Medical Center, Baltimore, Maryland; US Army Institute of Surgical Research (J.B.H.), Fort Sam Houston, Texas; Department of Surgery B (Y.K.), Rambam Medical Center, Haifa, Israel; Department of Emergency Medicine (K.M.-J.), Manchester Royal Infirmary, Manchester, United Kingdom; Intensive Care Unit (M.J.P.), Liverpool Hospital, University of New South Wales, Sydney, Australia; Sunnybrook Health Sciences Centre (S.B.R.), University of Toronto, Toronto, Ontario, Canada; Department of Emergency and Critical Care Medicine (T.Y.), Tokyo Medical University, Tokyo, Japan; and Department of Trauma and Orthopedic Surgery (B.B.), University of Witten/Herdecke, Cologne Merheim Medical Center, Cologne, Germany.

Submitted for publication March 29, 2008.

Accepted for publication June 4, 2008.

Support for survey development and implementation, meeting organization and medical writing support for article preparation were provided by Physicians World GmbH, Mannheim, Germany. Costs incurred for travel, hotel accommodation, meeting facilities, honoraria, survey implementation, and preparation of the article were supported by unrestricted educational grants from Novo Nordisk A/S, Bagsvaerd, Denmark.

B.B. has received honoraria for consulting or lecturing and research funding from Novo Nordisk.

R.P.D. has received honoraria for consulting or lecturing and educational grants from Novo Nordisk. He has received research grant funding from Novo Nordisk and Octapharma.

C.J.H. has received honoraria for consulting from Novo Nordisk.

J.R.H. has received honoraria for consulting or lecturing from Novo Nordisk, Hemerus Inc, Hemostasis LLC, Blood Systems, Inc. and the American Society of Hematology. He has received research grant funding from the National Heart Lung and Blood Institute and the U.S. Air Force.

J.B.H. reported no relevant financial associations.

D.B.H. has received educational support for projects administered by Physicians World GmbH.

Y.K. has received honoraria for lecturing from Novo Nordisk.

K.M.-J. has received research grant funding fro the UK NIHR and the DTI.

M.J.P. has received honoraria for consulting or lecturing from Novo Nordisk and research grant funding from Novo Nordisk and the Australian and New Zealand Intensive Care Society Clinical Trials Group.

S.B.R. has received honoraria for consulting or lecturing for Novo Nordisk and has received research grant funding from Defense Research and Development Canada and Physician Services Incorporated.

T.Y. has received honoraria for consulting from Novo Nordisk, has received study grants from the Japanese Ministry of Health and Labor, Grants-in-Aid for Scientific Research JSPS and has received institutional support from Tokyo Medical University.

The grantor had no authorship or editorial control over the content of the clinical practice survey or any subsequent publication.

Address for reprints: David B. Hoyt, MD, FACS, Department of Surgery, University of California, Irvine, City Tower, 333 City Boulevard, Suite 700, Orange, CA 92868; email:

© 2008 Lippincott Williams & Wilkins, Inc.