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Hamostaseologie 2021; 41(04): 307-315
DOI: 10.1055/a-1232-7721
Review Article

Trauma-Induced Coagulopathy and Massive Bleeding: Current Hemostatic Concepts and Treatment Strategies

Johannes Gratz
1   Department of Anaesthesiology, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Austria
,
Daniel Oberladstätter
2   Department of Anaesthesiology and Intensive Care, AUVA Trauma Centre, Salzburg, Austria
3   Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, AUVA Research Centre, Vienna, Austria
,
Herbert Schöchl
2   Department of Anaesthesiology and Intensive Care, AUVA Trauma Centre, Salzburg, Austria
3   Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, AUVA Research Centre, Vienna, Austria
› Author Affiliations Funding None.
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Abstract

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.

Zusammenfassung

Nach wie vor sind Blutungen die Ursache eines relevanten Anteils potentiell behandelbarer Todesfälle bei TraumapatientInnen. Das Auftreten einer trauma-induzierten Koagulopathie (TIC) bei Aufnahme ist mit einem schlechteren Outcome dieser PatientInnen assoziiert. TIC stellt eine komplexe Störung des Gerinnungssystems dar und wird durch Standardgerinnungstests nicht adäquat abgebildet. Aufgrund der umfassenderen Darstellung des Gerinnungsprozesses haben viskoelastische Tests (VET) an Bedeutung in der Charakterisierung von TIC gewonnen. VET werden daher zunehmend als bettseitig verfügbare gerinnungsspezifische Monitoringmöglichkeit verwendet. Die sogenannte “Damage-Control Resuscitation” sowie die frühzeitige Gabe von Tranexamsäure stellen die Basis der Behandlung von PatientInnen mit TIC dar. In der Hoffnung auf einen Überlebensvorteil haben viele Traumazentren weltweit Massivtransfusionsprotokolle eingeführt, welche eine frühzeitige und hochdosierte Transfusion von Plasma vorsehen. Plasma enthält alle Gerinnungsfaktoren sowie Gerinnungsinhibitoren; ein adäquater Ersatz der fehlenden Gerinnungsfaktoren bei blutenden PatientInnen kann jedoch nur durch Transfusion großer Volumina erreicht werden. Allerdings wurden für die Gabe großer Mengen an Plasmen relevante Risiken beschrieben. In einigen europäischen Traumazentren wird in diesem Zusammenhang zunehmend ein individualisiertes hämostatisches Therapiekonzept zur Behandlung von TraumapatientInnen verfolgt. Hierbei wird das individuelle, tatsächlich vorliegende Gerinnungsprofil der PatientInnen anhand von VET dargestellt. Die nachfolgende zielgerichtete Therapie basiert hauptsächlich auf der Gabe von Gerinnungsfaktorkonzentraten wie Fibrinogen oder Prothrombinkomplexkonzentrat. Ein klarer Vorteil in Bezug auf das Überleben der PatientInnen konnte jedoch bis jetzt für keine der beiden Therapiestrategien nachgewiesen werden. Das Ziel dieses Reviewartikel ist es, die aktuell verfügbare Literatur für unterschiedliche diagnostische und therapeutische Vorgehen bei PatientInnen mit TIC zusammenzufassen.

Keywords

trauma-induced coagulopathy - ratio-driven hemostatic therapy - goal-directed coagulation therapy - viscoelastic testing

Schlüsselwörter

trauma-induzierte Koagulopathie - verhältnisgesteuerte hämostatische Therapie - zielgerichtete Gerinnungstherapie - viskoelastische Prüfung


Publication History

Received: 09 May 2020

Accepted: 03 August 2020

Article published online:
07 September 2020

© 2020. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

 

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