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Coagulopathy Trauma-related Coagulopathy—Current Concepts Paul T Engels, MD FRCSC, FACS, 1 J Damian Paton-Gay, MD, FRCSC 1 and Sandy L Widder, MD, MHA, FRCSC 2 1. Clinical Lecturer; 2. Assistant Professor, Department of Surgery and Division of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada Abstract Background: Hemorrhage continues to be a major cause of early death in trauma patients. Our understanding of the development of coagulopathy and its importance has evolved significantly over the last decade. In this article, we describe the current understanding of coagulopathy in the setting of trauma including its mechanisms, diagnosis, consequences, and treatment strategies. Methods: Review of selected articles from MEDLINE. Results: The occurrence of coagulopathy is common in trauma patients and is multifactorial, with increasing evidence indicating an endogenous mechanism unrelated to the complications of medical treatment. The use of novel coagulation assessment techniques and evolution in blood product treatment strategies is generating a new era of targeted management. Conclusions: Coagulopathy in trauma is common, but newer techniques in diagnosis as well as novel methods to provide targeted treatment offer encouraging results in decreasing the mortality rate from exsanguination after injury. Keywords Trauma, coagulopathy, resuscitation, TEG, ROTEM, damage control resuscitation Disclosure: The authors have no conflicts of interest to disclose. Received: May 14, 2012 Accepted: September 11, 2012 Citation: Oncology & Hematology Review, 2012;8(2):123–8 Correspondence: Paul T Engels, Royal Alexandra Hospital, Room 205, CSC, 10240 Kingsway Avenue NW, Edmonton, Alberta, T5H 3V9, Canada. E: pengels@ualberta.ca Tissue trauma induces alterations in the inflammatory and coagulation systems; in fact, the absence of such responses would almost certainly have resulted in our demise long ago. Along with our protective evolutionary devices, we have also increased our understanding of the coagulopathy induced by trauma over the last few decades—including its distinctive yet parallel interplay with iatrogenic-induced coagulopathy. Hemorrhage is recognized as the second leading cause of death in trauma patients overall and the leading cause of death during the first few hours of hospital care. 1 Coagulopathic bleeding in the setting of major trauma was recognized over 30 years ago, with the description of the vicious cycle of bleeding, tissue hypoxia, hypothermia, acidosis, and coagulopathy 2 (see Figure 1). In 2003, seminal studies by Brohi et al. 3 and MacLeod et al. 4 identified the presence of coagulopathy early after trauma, as well as its association with increasing injury severity 3 and that it carries an associated increased risk of death. 4 Research in this area has exploded, with many research groups seeking to better elucidate the mechanisms behind this coagulopathy as well as decipher how best to treat it. The publication, in 2007, of Borgman’s retrospective study demonstrating the reduction in mortality of severely injured combat soliders by transfusing large volumes of plasma 5 incited a pursuit to validate this treatment strategy for traumatic coagulopathy. In this article, we will seek to describe the current understanding of coagulopathy in the setting of trauma including its mechanisms, diagnosis, consequences, and treatment strategies. © TOUCH BRIEFINGS 2012 Nomenclature The coagulopathy seen in trauma patients is currently referred to in the literature by many names. The terms trauma-induced coagulopathy (TIC), 6 early trauma-induced coagulopathy (ETIC), 7 acute traumatic coagulopathy (ATC), 3 endogenous acute coagulopathy (EAC), 8 systemic acquired coagulopathy (SAC), 8 acute coagulopathy of trauma shock (ACoTS), 9 and disseminated intravascular coagulation (DIC) with fibrinolytic or thrombotic phenotypes 10 have all been used to describe the coagulopathy seen in trauma. Indeed, this variability in its definitions reflects the current uncertainty and debate over the key mechanisms responsible for it. TIC is an overarching term used to describe the coagulopathy that is related to and occurs after traumatic injury. It is multifactorial in etiology and includes the potential contributions from medical interventions, such as hypothermia, acidosis, and hemodilution. 6 ATC was described by Brohi et al. 3 in 2003. It has most recently been characterized by a reduction in clot strength with a specific thromboelastometry signature that can be diagnosed by the CA5 (clot amplitude) parameter on ROTEM ® (rotational thromboelastometry, TEM International, Munich, Germany). It can rapidly identify patients who are likely to require a massive transfusion. 11 The use of a PTr (prothrombin time ratio) >1.2 has been recommended as a clinically relevant definition of ATC. 12 EAC and ETIC are largely synonymous with ATC, as they represent changes in the coagulation system, induced by 123