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World J Anesthesiol. Mar 27, 2014; 3(1): 111-118
Published online Mar 27, 2014. doi: 10.5313/wja.v3.i1.111
Acute coagulopathy of trauma: Mechanism, monitoring, management
Anusha Cherian, Bidkar Prasanna Udupi
Anusha Cherian, Bidkar Prasanna Udupi, Department of Anaesthesiology and Critical Care, Jawaharlal Institute of Post-graduate Medical Education and Research, Pondicherry 605006, India
Author contributions: Cherian A and Bidkar PU contributed equally to the manuscript.
Correspondence to: Anusha Cherian, Assistant Professor, Department of Anaesthesiology and Critical Care, Jawaharlal Institute of Post-graduate Medical Education and Research, 605006 Pondicherry, India. anushacherian@gmail.com
Telephone: +91-978-9197801 Fax: +413-227-2735
Received: November 11, 2013
Revised: January 14, 2014
Accepted: February 20, 2014
Published online: March 27, 2014
Processing time: 120 Days and 10.4 Hours
Abstract

Coagulopathy is a well-known consequence of trauma and is the most common cause of mortality in the young. However, its cause and management is still controversial. A new concept in the understanding of coagulopathy in trauma is the occurrence of Acute coagulopathy of trauma (ACoT). ACoT is associated with hypo perfusion and tissue trauma as seen in massive injury. The incidence of coagulopathy increases with injury scores and is associated with higher number of ventilator days, higher morbidity and mortality. The process of coagulation is better described by the cell based model with a central role for platelets rather than the older plasma based model. This shift in our understanding supports the theory that ACoT results from the endothelial release of thrombomodulin and activated protein C in the presence of hypoperfusion. This in turn leads on to a hyperfibrinolytic and hypocoagulable state. Viscoelastic hemostatic assays are replacing the older tests like prothrombin time in the assessment of coagulopathy. These tests are accurate, determine the need for transfusion and can be performed at the point of care. Damage control resuscitation includes newer concepts like permissive hypotension, increased use of plasma as a part of massive transfusion protocols and damage control surgery.

Keywords: Trauma; Coagulopathy; Massive transfusion; Bleeding; Thromboelastography

Core tip: Coagulopathy associated with trauma is a poorly understood and managed complication seen in severely injured patients. Acute coagulopathy of trauma, as it is currently described is attributed to trauma shock and associated tissue hypoperfusion. The traditionally attributed causes of acidosis and hypothermia contribute to a delayed form of coagulopathy, which is now considered different from early coagulopathy. Timely and appropriate use of blood and blood products along with the management of hypotension is termed damage control resuscitation. Early treatment to reverse and prevent acidosis, hypothermia and coagulopathy is the main focus.