Traumatic coagulopathy--part 1: Pathophysiology and diagnosis

Role of the admission muscle injury indicators in early coagulopathy, inflammation and acute kidney injury in patients with severe multiple injuries

BACKGROUNDS

Coagulopathy, inflammation and organ failure are common complications in trauma patients. This study aimed to explore the possible role of muscle injury indicators in early coagulopathy, systemic inflammatory response syndrome (SIRS), and acute kidney injury (AKI) in patients with severe multiple trauma.

METHODS

A retrospective analysis was performed using trauma center patient data from 2020 to 2023. The incidence of coagulopathy, SIRS and AKI in patients with multiple injuries were assessed. The relationship between Myoglobin, creatine kinase (CK), lactate dehydrogenase (LDH) and trauma severity was investigated, and the influence of these three muscle injury indicators on patient adverse outcomes was analyzed.

RESULTS

A total of 312 patients with severe multiple injuries were included in this study, with an average age of 51.7 and a median Injury Severity Score (ISS) of 22.5. Among them, 115 patients developed coagulopathy, 169 patients developed SIRS, 26 patients developed AKI, and 11 patients died during hospitalization. We found that Myoglobin (r = 0.225, P < 0.001), CK (r = 0.204, P < 0.001), LDH (r = 0.175, P = 0.002) were positively correlated with ISS. Myoglobin is an independent risk factor for coagulopathy (OR = 1.90, 95%CI: 1.45-2.49), SIRS (OR = 1.41, 95%CI: 1.10-1.79), and AKI (OR = 4.17, 95%CI: 2.19-7.95). CK is an independent risk factor for coagulopathy (OR = 1.30, 95%CI: 1.00-1.67), while LDH is an independent risk factor for SIRS (OR = 1.49, 95%CI: 1.17-1.89) and AKI (OR = 2.30, 95%CI: 1.43-3.69). Especially for AKI, Myoglobin had a good predictive effect (AUC = 0.804, 95%CI:0.716-0.891). The best cut-off value is when the Myoglobin value is 931.11 µg/L, at which point the sensitivity is 61.53% and the specificity is 87.41%.

CONCLUSIONS

The admission muscle injury index can predict trauma complications such as AKI, early coagulation disease, and SIRS, especially AKI. Compared to CK and LDH, admission myoglobin can predict complications remarkably, even better than ISS, especially AKI. Routine testing of muscle injury indicators upon admission is meaningful and can help physicians identify and prevent the occurrence of complications.

A nomogram based on trauma-induced coagulopathy for predicting hospital mortality in multi-trauma patients: a retrospective study

Multi-trauma presents significant challenges due to the complexity of injuries and high mortality rates. Early identification and intervention are crucial for improving outcomes in these critically injured patients. This retrospective study analyzed clinical data from multi-trauma patients admitted to the emergency department of Huiyang Sanhe Hospital between January 10, 2020, and September 30, 2022. Univariate and multivariate logistic regression analyses were conducted to identify independent predictors of hospital mortality. A prediction model was developed based on these prognostic markers, visualized using a nomogram, and its discriminative ability and clinical benefit were evaluated. A total of 124 multi-trauma patients were included in the study, with a hospital mortality rate of 26.7%. Univariate and multivariate logistic regression analyses identified trauma-induced coagulopathy (TIC) (OR 4.238, 95% CI 1.46-12.28), blood urea nitrogen (BUN) (OR 1.397, 95% CI 1.09-1.78), and Glasgow Coma Scale (GCS) score (OR 0.720, 95% CI 0.61-0.85) as independent factors of hospital mortality. Therefore, a nomogram incorporating TIC, BUN, and GCS score was constructed and demonstrated excellent predictive performance and clinical impact (AUC 0.898, 95% CI 0.834-0.962). The nomogram developed in this study provided a practical tool for early prediction of hospital mortality in multi-trauma patients. By focusing on TIC, BUN, and GCS score, this model may facilitate rapid bedside assessment and timely intervention. However, further multicenter, prospective studies are required to validate its performance and applicability.

Elevated international normalized ratio contributes to poor prognosis in patients with traumatic lung injury

Objective

To investigate the pivotal determinants contributing to the adverse prognosis in patients afflicted with traumatic lung injury (TLI), with an aim to mitigate the elevated mortality rate associated with this condition.

Methods

A retrospective analysis was carried out on 106 TLI patients who were admitted to the intensive care unit of a comprehensive hospital from March 2018 to November 2022. The patients were categorized into two groups based on their 28-day outcome: the survival group (n = 88) and the death group (n = 18). Random forest model, least absolute shrinkage and selection operator (LASSO) regression and support vector machine recursive feature elimination (SVM-RFE) were utilized to pinpoint the primary factors linked to poor prognosis in TLI patients. The Receiver Operating Characteristic (ROC) curve analysis was utilized to ascertain the predictive value of INR in forecasting the prognosis of TLI patients. Based on the cut-off value of INR, patients were categorized into two groups: INR ≥ 1.36 group (n = 35) and INR < 1.36 group (n = 71). The 28-day survival rate was then compared using Kaplan-Meier analysis.

Results

Random forest model, LASSO, and SVM-RFE jointly identified International standardization ratio (INR) as a risk factor for TLI patients. The area under the ROC curve for INR in predicting the 28-day mortality of TLI patients was 0.826 (95% CI 0.733-0.938), with a cut-off value of 1.36. The 28-day mortality risk for TLI patients with an INR ≥ 1.36 was 8.5 times higher than those with an INR < 1.36.

Conclusion

Traumatic lung injury patients with elevated INR have a poor prognosis. An INR of ≥1.36 can be used as an early warning indicator for patients with traumatic lung injury.

Breaking barriers in trauma research: A narrative review of opportunities to leverage veterinary trauma for accelerated translation to clinical solutions for pets and people

Trauma is a common cause of morbidity and mortality in humans and companion animals. Recent efforts in procedural development, training, quality systems, data collection, and research have positively impacted patient outcomes; however, significant unmet need still exists. Coordinated efforts by collaborative, translational, multidisciplinary teams to advance trauma care and improve outcomes have the potential to benefit both human and veterinary patient populations. Strategic use of veterinary clinical trials informed by expertise along the research spectrum (i.e., benchtop discovery, applied science and engineering, large laboratory animal models, clinical veterinary studies, and human randomized trials) can lead to increased therapeutic options for animals while accelerating and enhancing translation by providing early data to reduce the cost and the risk of failed human clinical trials. Active topics of collaboration across the translational continuum include advancements in resuscitation (including austere environments), acute traumatic coagulopathy, trauma-induced coagulopathy, traumatic brain injury, systems biology, and trauma immunology. Mechanisms to improve funding and support innovative team science approaches to current problems in trauma care can accelerate needed, sustainable, and impactful progress in the field. This review article summarizes our current understanding of veterinary and human trauma, thereby identifying knowledge gaps and opportunities for collaborative, translational research to improve multispecies outcomes. This translational trauma group of MDs, PhDs, and DVMs posit that a common understanding of injury patterns and resulting cellular dysregulation in humans and companion animals has the potential to accelerate translation of research findings into clinical solutions.

High-rise syndrome in cats and dogs

OBJECTIVE

To review the current literature pertaining to the pathophysiology, diagnosis, and treatment of injuries sustained from high-rise syndrome in cats and dogs.

ETIOLOGY

High-rise syndrome is defined as a fall from a height of 2 or more stories that results in a constellation of injuries, including thoracic, abdominal, orthopedic, and orofacial trauma. Animals often fall after slipping from windowsills, engaging in mating behavior, or chasing prey. Cats suffer less severe injuries than dogs due to their "righting reflex" and smaller body mass. Affected animals are younger, and the frequency of falls is higher in warmer months.

DIAGNOSIS

Physical examination coupled with radiographs, ultrasound, and computed tomography can diagnose a myriad of injuries that include pneumothorax, pleural or abdominal effusion, orthopedic fractures, and orofacial injuries. Bloodwork may identify anemia, thrombocytopenia, or increases in hepatic, renal, or pancreatic values consistent with trauma to these organs. Serial venous or arterial blood gas can help determine the severity of respiratory compromise and influence resuscitative efforts. Traditional coagulation tests and thromboelastography can assess trauma-induced coagulopathy and guide transfusion therapy.

THERAPY

Animals presenting in shock require hemodynamic stabilization. Initial resuscitation may incorporate crystalloids, colloids, blood products, and analgesics. Thoracic injuries may require oxygen, thoracocentesis, chest tube placement, and mechanical ventilation. Fractures and wounds are decontaminated and splinted/bandaged, with definitive fixation pursued after stabilization. Abdominal injuries are managed medically unless there is severe ongoing bleeding, sepsis, or injury to the urinary tract.

PROGNOSIS

In feline high-rise syndrome, the prognosis is generally excellent following treatment, with survival exceeding 90%. Canine literature is sparse. The largest retrospective study reported a >90% survival to discharge and a greater need for surgical stabilization in this species. There are no prognostic factors identified that are associated with survival for either species.

Attempt for a Recombinant Thrombomodulin Alpha Treatment in a Rat Disseminated Intravascular Coagulation Model Using Yamakagashi (Rhabdophis tigrinus) Venom

Yamakagashi (Rhabdophis tigrinus) inhabits Japan widely, and incidents involving its bites occur every year. Its bite causes disseminated intravascular coagulation when the amount of infused venom is high, and it can be fatal if treatment with Yamakagashi antivenom is delayed. Although Yamakagashi antivenom is used for treating Yamakagashi bites, it is an unapproved drug and its capacity for storage is limited. Hence, it is difficult to administer to patients promptly. As a therapeutic agent for this bite, we investigated the application of recombinant thrombomodulin alpha, a commercially available disseminated intravascular coagulation therapeutic agent. Its therapeutic effect on Yamakagashi venom was confirmed in a coagulation system of human plasma using in vitro Yamakagashi venom as well as a rat experimental model of disseminated intravascular coagulation using in vivo Yamakagashi venom. The administration of recombinant thrombomodulin alpha induced an effect that prolonged the blood coagulation time of Yamakagashi venom in vitro, and the drug was administered in vivo within 0.5 h after the administration of Yamakagashi venom to save rats. Blood coagulation markers such as platelet count, prothrombin time, fibrinogen concentration, and D-dimer levels recovered to normal values in rats. Therefore, recombinant thrombomodulin alpha may be used as a therapeutic agent for Yamakagashi bites.

Pathophysiology of hemorrhagic shock

BACKGROUND

Hemorrhagic shock is a common condition that may lead to hemodynamic instability, decreased oxygen delivery, cellular hypoxia, organ damage, and ultimately death.

CLINICAL IMPORTANCE

This review addresses the pathophysiology of hemorrhagic shock. Hemorrhagic shock can be rapidly fatal and is the leading cause of death in human trauma patients. Understanding the pathophysiology of hemorrhagic shock is imperative in understanding the current hemostatic and resuscitative strategies and is foundational to the development of new therapeutic options.

KEY POINTS

Shock is a state of inadequate cellular energy production and can be triggered by many causes Both traumatic and non-traumatic causes of hemorrhage can lead to the development of hemorrhagic shock Prompt recognition and attenuation of hemorrhage is paramount in preventing the onset or potentiation of hemorrhagic shock Acute hemorrhage produces distinct physiological responses depending on the magnitude and rate of hemorrhage. Hemorrhagic shock may be directly related to the initial injury but may also be exacerbated and complicated by a post-traumatic coagulopathy, termed acute traumatic coagulopathy.

Assessment of hemostasis in dogs with gastric-dilation-volvulus, during resuscitation with hydroxyethyl starch (130/0.4) or hypertonic saline (7.5%)

OBJECTIVE

To compare the impact of an IV bolus of hydroxyethyl starch 130/0.4 (HES) or hypertonic saline 7.5% (HS) on hemostasis in dogs resuscitated for gastric-dilation-volvulus (GDV).

DESIGN

Open-label, parallel-group randomized clinical trial.

ANIMALS

Twenty-three client-owned dogs.

INTERVENTIONS

Dogs affected by GDV and shock were randomly assigned to receive HES at 10 mL/kg or HS at 4 mL/kg every 15 minutes. Blood samples were collected for blood gas analysis, PCV, total plasma protein, albumin, standard coagulation profile, and thromboelastometry (ROTEM) at baseline (T0) and at the end of bolus (T1). To assess the differences between the 2 groups at T1, Student's t-test or Wilcoxon rank-sum test was used. To evaluate the differences between T0 and T1, ANOVA for paired data or Wilcoxon matched-pairs signed-ranks test was used. P < 0.05 was considered significant.

MEASUREMENT AND MAIN RESULTS

Hemostasis was evaluated by means of prothrombin time, activated partial thromboplastin time, fibrinogen, and ROTEM. The study included 13 dogs in the HES group and 10 dogs in the HS group. Differences were found between groups at T1: increase in clotting time (P = 0.018) and decrease in fibrinogen level (P = 0.021) in the HS-treated group. Between T0 and T1, there were differences for the HES group: increase in clot formation time (P = 0.046), decrease in maximum clot firmness (P = 0.002) in ex-TEM profile, and decrease in maximum clot firmness (P = 0.0117) in fib-TEM profile. Between T0 and T1, the following differences were noted for the HS group: increase in clotting time (P = 0.048) and clot formation time (P = 0.0019), decrease in maximum clot firmness (P = 0.031) and α angle (P = 0.036) in ex-TEM profile, decrease in α angle (P = 0.036) in in-TEM profile, and decrease in maximum clot firmness (P = 0.017) in fib-TEM profile.

CONCLUSION

In dogs affected by GDV, HES or HS infusion caused a similar tendency toward hypocoagulability, with few differences between the 2 groups.

Hemorrhagic shock and hemostatic resuscitation in canine trauma

Hemorrhage is a significant cause of death among military working dogs and in civilian canine trauma. While research specifically aimed at canine trauma is limited, many principles from human trauma resuscitation apply. Trauma with significant hemorrhage results in shock and inadequate oxygen delivery to tissues. This leads to aberrations in cellular metabolism, including anaerobic metabolism, decreased energy production, acidosis, cell swelling, and eventual cell death. Considering blood and endothelium as a single organ system, blood failure is a syndrome of endotheliopathy, coagulopathy, and platelet dysfunction. In severe cases following injury, blood failure develops and is induced by inadequate oxygen delivery in the presence of hemorrhage, tissue injury, and acute stress from trauma. Severe hemorrhagic shock is best treated with hemostatic resuscitation, wherein blood products are used to restore effective circulating volume and increase oxygen delivery to tissues without exacerbating blood failure. The principles of hemostatic resuscitation have been demonstrated in severely injured people and the authors propose an algorithm for applying this to canine patients. The use of plasma and whole blood to resuscitate severely injured canines while minimizing the use of crystalloids and colloids could prove instrumental in improving both mortality and morbidity. More work is needed to understand the canine patient that would benefit from hemostatic resuscitation, as well as to determine the optimal resuscitation strategy for these patients.

Endothelial glycocalyx degradation is associated with early organ impairment in polytrauma patients

BACKGROUND

Endothelial glycocalyx (EG) abnormal degradation were widely found in critical illness. However, data of EG degradation in multiple traumas is limited. We performed a study to assess the EG degradation and the correlation between the degradation and organ functions in polytrauma patients.

METHODS

A prospective observational study was conducted to enroll health participants (control group) and polytrauma patients (trauma group) at a University affiliated hospital between Feb 2020 and Oct 2020. Syndecan1 (SDC1) and heparin sulfate (HS) were detected in serum sample of both groups. In trauma group, injury severity scores (ISS) and sequential organ failure assessments (SOFA) were calculated. Occurrences of acute kidney injury (AKI), trauma-induced coagulopathy (TIC) within 48 h and 28-day all-cause mortality in trauma group were recorded. Serum SDC1 and HS levels were compared between two groups. Correlations between SDC1/HS and the indicators of organ systems in the trauma group were analyzed. ROC analyses were performed to assess the predictive value of SDC1 and HS for AKI, TIC within 48 h, and 28-day mortality in trauma group.

RESULTS

There were 45 polytrauma patients and 15 healthy participants were collected, totally. SDC1 and HS were significantly higher in trauma group than in control group (69.39 [54.18-130.80] vs. 24.15 [13.89-32.36], 38.92 [30.47-67.96] vs. 15.55 [11.89-23.24], P <  0.001, respectively). Trauma group was divided into high degradation group and low degradation group according to SDC1 median. High degradation group had more severe ISS, SOFA scores, worse organ functions (respiratory, kidney, coagulation and metabolic system), and higher incidence of hypothermia, acidosis and shock. The area under the receiver operator characteristic curves (AUC) of SDC1 to predict AKI, TIC occurrence within 48 h and 28-day mortality were 0.838 (95%CI: 0.720-0.957), 0.700 (95%CI: 0.514-0.885) and 0.764 (95%CI: 0.543-0.984), respectively.

CONCLUSIONS

EG degradation was elevated significantly in polytrauma patients, and the degradation was correlated with impaired respiratory, kidney, coagulation and metabolic systems in early stage. Serum SDC1 is a valuable predictive indicator of early onset of AKI, TIC, and 28-day mortality in polytrauma patients.

The role of cryoprecipitate in human and canine transfusion medicine

OBJECTIVE

To evaluate the current role of cryoprecipitate in human and canine transfusion medicine.

DATA SOURCES

Human and veterinary scientific reviews and original studies found using PubMed and CAB Abstract search engines were reviewed.

HUMAN DATA SYNTHESIS

In the human critical care setting, cryoprecipitate is predominantly used for fibrinogen replenishment in bleeding patients with acute traumatic coagulopathy. Other coagulopathic patient cohorts for whom cryoprecipitate is recommended include those undergoing cardiovascular or obstetric procedures or patients bleeding from advanced liver disease. Preferential selection of cryoprecipitate versus fibrinogen concentrate (when available) is currently being investigated. Also a matter of ongoing debate is whether to administer this product as part of a fixed-dose massive hemorrhage protocol or to incorporate it into a goal-directed transfusion algorithm applied to the individual bleeding patient.

VETERINARY DATA SYNTHESIS

Although there are sporadic reports of the use of cryoprecipitate in dogs with heritable coagulopathies, there are few to no data pertaining to its use in acquired hypofibrinogenemic states. Low fibrinogen in dogs (as in people) has been documented with acute traumatic coagulopathy, advanced liver disease, and disseminated intravascular coagulation. Bleeding secondary to these hypocoagulable states may be amenable to cryoprecipitate therapy. Indications for preferential selection of cryoprecipitate (versus fresh frozen plasma) remain to be determined.

CONCLUSIONS

In the United States, cryoprecipitate remains the standard of care for fibrinogen replenishment in the bleeding human trauma patient. Its preferential selection for this purpose is the subject of several ongoing human clinical trials. Timely incorporation of cryoprecipitate into the transfusion protocol of the individual bleeding patient with hypofibrinogenemia may conserve blood products, mitigate adverse transfusion-related events, and improve patient outcomes. Cryoprecipitate is readily available, effective, and safe for use in dogs. The role of this blood product in clinical canine patients with acquired coagulopathy remains unknown.

Prevalence of Acute Traumatic Coagulopathy in Acutely Traumatized Dogs and Association with Clinical and Laboratory Parameters at Presentation

OBJECTIVE

 The aim of this study was to determine the prevalence of acute traumatic coagulopathy (ATC) and identify associated clinical and laboratory parameters including rotational thromboelastometry.

STUDY DESIGN

 Dogs presenting within 6 hours after trauma were allocated to the ATC or non-ATC group based on thromboelastometry analysis (ex-tem S, in-tem S, fib-tem S). ATC was defined as ≥2 hypocoagulable parameters in 1 profile and ≥ 1 hypocoagulable parameter in an additional profile. Parameters used were ex-tem and in-tem clotting time (CT), clot formation time (CFT), maximum clot firmness (MCF), maximum lysis and fib-tem MCF. Clinical and laboratory parameters at presentation, animal trauma triage (ATT) score, transfusion requirement and outcome were compared. Logistic regression was used to identify independent factors associated with ATC.

RESULTS

 Eleven of 33 dogs presented with ATC and showed ex-tem CT and CFT prolongation and reduced MCF amplitude in all profiles (all p < 0.001). pH (p = 0.043) and potassium concentration (p = 0.022) were significantly lower and bleeding (p = 0.027) and plasma transfusions (p = 0.001) more common in dogs with ATC. Time after trauma (p = 0.040) and Animal Trauma Triage score (p = 0.038, including haematocrit as confounding factor) were associated with the presence of ATC.

CONCLUSION

 Acute traumatic coagulopathy is more common in traumatized dogs than previously reported. Acute traumatic coagulopathy was associated with acidosis, Animal trauma triage score, time after trauma and higher transfusion needs. Coagulation abnormalities include ex-tem CT and CFT prolongations and decreased clot strength.

Effects of refrigerated storage on hemostatic stability of four canine plasma products

OBJECTIVE

To assess clotting times, coagulation factor activities, sterility, and thromboelastographic parameters of liquid plasma (LP), thawed fresh frozen plasma (FFP-T), and 2 novel formulations of freeze-dried plasma (FDP) stored refrigerated over 35 days.

SAMPLE

6 units of canine LP and FFP-T from a commercial animal blood bank and 5 units each of 2 formulations of canine FDP.

PROCEDURES

Prothrombin time; activated partial thromboplastin time; activities of coagulation factors II, V, VII, VIII, IX, X, XI, and XII; and thromboelastographic parameters were determined for each product on days 0 (baseline), 3, 7, 14, 21, 28, and 35. For each day, a sample of each product was also submitted for aerobic bacterial culture.

RESULTS

Small changes in coagulation factor activities and mild increased time to initial clot formation in LP and FFP-T were noted over the 35-day storage period. Activities of factor VIII in FDP1 and factor XII in FDP2 were < 50% at baseline but varied throughout. Compared with FFP-T, time to initial clot formation was increased and clot strength was preserved or increased for the FDPs throughout the study. One FDP had decreased pH, compared with other products. No plasma product yielded bacterial growth.

CONCLUSIONS AND CLINICAL RELEVANCE

Liquid plasma and FFP-T would be reasonable to use when stored refrigerated for up to 35 days. Both FDP products showed variability in coagulation factor activities. Studies investigating the usefulness of these plasma products (FDPs) in dogs and the variable days of refrigerated storage (all products) are warranted. (Am J Vet Res 2020;81:964-972).

A prospective randomized open-label trial on the comparative effects of 6% hydroxyethyl starch 130/0.4 versus polyionic isotonic crystalloids on coagulation parameters in dogs with spontaneous hemoperitoneum

OBJECTIVE

To evaluate the effects of 6% hydroxyethyl starch 130/0.4 (HES) and a polyionic isotonic crystalloid (CRYS) on standard coagulation tests and rotational thromboelastometry (ROTEM) in dogs with spontaneous hemoperitoneum (SHP).

DESIGN

Prospective randomized open-label clinical study.

SETTING

University teaching hospital.

ANIMALS

Forty-two client-owned dogs presented with SHP.

INTERVENTIONS

Dogs diagnosed with SHP and hypovolemic shock were randomly allocated to receive HES (10 mL/kg, n = 22) or CRYS (30 mL/kg, n = 20) intravenously over 20 minutes for hemodynamic stabilization.

MEASUREMENTS AND MAIN RESULTS

Parameters measured before (T₀ ) and after (T₁ ) treatment were HCT, platelet counts, prothrombin time, activated partial thromboplastin time, fibrinogen concentrations, and extrinsic activated (EXTEM), intrinsic activated (INTEM), and extrinsic activated with platelet inhibition ROTEM assays. Data were analyzed as absolute values and as the percentage change from T₀ to T₁ . No significant differences between groups were detected in any variable at T₀ , and for HCT, platelet counts, prothrombin time, activated thromboplastin time, and fibrinogen concentrations at T₁ . Clot formation time in EXTEM was significantly prolonged (P = 0.037), and maximum clot firmness was significantly decreased (P = 0.038) in the HES group compared to the CRYS group at T₁ . The percentage change in EXTEM clotting time (P = 0.012) and INTEM clot formation time (P = 0.031) was greater after HES than CRYS. Lysis indices remained at 100% for all ROTEM assays in both groups.

CONCLUSION

Compared to a 3-fold volume of CRYS, administration of HES was associated with impairment in ROTEM parameters in dogs with SHP, but no evidence of hyperfibrinolysis was detected.

Effect of 7.5% hypertonic saline solution on whole blood coagulation in healthy dogs using thromboelastography

Objective

To evaluate the effects of 7.5% hypertonic saline solution (HSS) on whole blood coagulation in healthy dogs and to compare electrolyte and osmolality measurements between in vivo and in vitro dilution with HSS.

Design

Experimental study.

Setting

University teaching hospital.

Animals

Twelve adult purpose‐bred Beagles.

Interventions

All 12 dogs received 5 mL/kg 7.5% HSS at 1 mL/kg/min. After a 14‐day washout period, 5 of these dogs were randomly selected and received the same volume of 0.9% NaCl. Blood samples were collected before infusion, immediately after infusion, and at 30, 60, and 90 minutes after infusion for the measurement of coagulation using thromboelastography. For comparison of electrolyte concentrations and osmolality between in vitro dilution and in vivo dilution of HSS, 6‐mL blood samples were diluted with 7.5% HSS (1:18 ratio) at baseline.

Measurements and Main Results

None of the thromboelastography variables differed significantly between the 7.5% HSS group and the 0.9% NaCl group. The sodium and chloride levels, and the osmolality, were significantly increased at all postinfusion time points compared to baseline, while those levels were significantly higher with in vitro dilution than all postinfusion time points. However, almost all the values gradually decreased and became similar to baseline values in case of in vivo dilution.

Conclusions

The clinically relevant dose of 7.5% HSS (5 mL/kg) did not affect whole blood coagulation significantly in healthy Beagles. Further studies are necessary to assess the effect of HSS on blood coagulation in canine patients with shock.

Higher Concentration of Hypertonic Saline Shows Better Recovery Effects on Rabbits with Uncontrolled Hemorrhagic Shock

Background

Our previous study found a novel fluid combination with better resuscitation effects under hypotensive condition at the early stage of uncontrolled hemorrhagic shock (UHS). However, the optimal recovery concentration of hypertonic saline in this fluid combination remains unknown. This experiment aimed to explore the optimal concentration.

Material/Methods

New Zealand white rabbits (n=40) were randomly divided into 5 groups, including a sham-operated group (SO), a shock non-treated group (SNT), a normal saline group (NS), and hypertonic saline groups (4.5% and 7.5%). We established an UHS model and administered various fluid combinations (dose-related sodium chloride solution+crystal-colloidal solution) to the groups followed by monitoring indexes of hemodynamic and renal function, measuring infusion volume and blood loss, and analyzing pathological morphology by hematoxylin and eosin staining.

Results

The hypertonic saline groups showed more stable hemodynamic indexes, reduced blood loss, fewer required infusions, and milder decreases in renal function than those of control groups (SNT and NS groups), and exhibited fewer pathological changes in the heart, lung, kidney, and liver. All indexes in the 4.5% and 7.5% groups were better than those of the NS group, and the hemodynamic indexes in the 7.5% group were more stable than those of the 4.5% group (P<0.05), with reduced blood loss and infusion volume and a milder decrease in renal function.

Conclusions

The novel fluid combination with 7.5% hypertonic saline group had a better recovery effect at the early stage of UHS before hemostasis compared to that of the 4.5% hypertonic saline group. This result may provide guidance for clinical fluid resuscitation.

A review of hyperfibrinolysis in cats and dogs

The fibrinolytic system is activated concurrently with coagulation; it regulates haemostasis and prevents thrombosis by restricting clot formation to the area of vascular injury and dismantling the clot as healing occurs. Dysregulation of the fibrinolytic system, which results in hyperfibrinolysis, may manifest as clinically important haemorrhage. Hyperfibrinolysis occurs in cats and dogs secondary to a variety of congenital and acquired disorders. Acquired disorders associated with hyperfibrinolysis, such as trauma, cavitary effusions, liver disease and Angiostrongylus vasorum infection, are commonly encountered in primary care practice. In addition, delayed haemorrhage reported in greyhounds following trauma and routine surgical procedures has been attributed to a hyperfibrinolytic disorder, although this has yet to be characterised. The diagnosis of hyperfibrinolysis is challenging and, until recently, has relied on techniques that are not readily available outside referral hospitals. With the recent development of point-of-care viscoelastic techniques, assessment of fibrinolysis is now possible in referral practice. This will provide the opportunity to target haemorrhage due to hyperfibrinolysis with antifibrinolytic drugs and thereby reduce associated morbidity and mortality. The fibrinolytic system and the conditions associated with increased fibrinolytic activity in cats and dogs are the focus of this review article. In addition, laboratory and point-of-care techniques for assessing hyperfibrinolysis and antifibrinolytic treatment for patients with haemorrhage are reviewed.

Early Identification of Acute Traumatic Coagulopathy Using Clinical Prediction Tools: A Systematic Review

: Background and objectives: Prompt identification of patients with acute traumatic coagulopathy (ATC) is necessary to expedite appropriate treatment. An early clinical prediction tool that does not require laboratory testing is a convenient way to estimate risk. Prediction models have been developed, but none are in widespread use. This systematic review aimed to identify and assess accuracy of prediction tools for ATC. Materials and Methods: A search of OVID Medline and Embase was performed for articles published between January 1998 and February 2018. We searched for prognostic and predictive studies of coagulopathy in adult trauma patients. Studies that described stand-alone predictive or associated factors were excluded. Studies describing prediction of laboratory-diagnosed ATC were extracted. Performance of these tools was described. Results: Six studies were identified describing four different ATC prediction tools. The COAST score uses five prehospital variables (blood pressure, temperature, chest decompression, vehicular entrapment and abdominal injury) and performed with 60% sensitivity and 96% specificity to identify an International Normalised Ratio (INR) of >1.5 on an Australian single centre cohort. TICCS predicted an INR of >1.3 in a small Belgian cohort with 100% sensitivity and 96% specificity based on admissions to resuscitation rooms, blood pressure and injury distribution but performed with an Area under the Receiver Operating Characteristic (AUROC) curve of 0.700 on a German trauma registry validation. Prediction of Acute Coagulopathy of Trauma (PACT) was developed in USA using six weighted variables (shock index, age, mechanism of injury, Glasgow Coma Scale, cardiopulmonary resuscitation, intubation) and predicted an INR of >1.5 with 73.1% sensitivity and 73.8% specificity. The Bayesian network model is an artificial intelligence system that predicted a prothrombin time ratio of >1.2 based on 14 clinical variables with 90% sensitivity and 92% specificity. Conclusions: The search for ATC prediction models yielded four scoring systems. While there is some potential to be implemented effectively in clinical practice, none have been sufficiently externally validated to demonstrate associations with patient outcomes. These tools remain useful for research purposes to identify populations at risk of ATC.

Hypocoagulability and Platelet Dysfunction Are Exacerbated by Synthetic Colloids in a Canine Hemorrhagic Shock Model

Background: Hemorrhagic shock and volume replacement can alter coagulation. Synthetic colloids, hydroxyethyl starch (HES), and gelatin, may enhance hypocoagulability. Our primary objective was to describe the effect of four fluid products on coagulation in canine hemorrhagic shock. Our secondary objective was to compare measurements of coagulation during shock to baseline in all dogs.

Methods: Anesthetized greyhounds subjected to atraumatic hemorrhage for 60 min were administered 20 mL kg⁻¹ of either fresh whole blood (FWB), 6% HES 130/0.4, 4% succinylated gelatin (GELO), or 80 mL kg⁻¹ of isotonic crystalloid over 20 min (n = 6 per group). Platelet closure time (PCT), rotational thromboelastometry (ROTEM) and plasma coagulation assays were measured at baseline, end of hemorrhage (shock), and 40 (T60), and 160 (T180) min after study fluid. ROTEM parameters included clotting time (CT), clot formation time (CFT), alpha angle, maximum clot firmness (MCF), lysis index at 60 min (LI60), and thrombodynamic potential index (TPI) for INTEM, EXTEM, FIBTEM (MCF only), and APTEM (LI60 only) profiles. Plasma coagulation assays included prothrombin time (PT), activated partial thromboplastin time (APTT), fibrinogen concentration and activities of factor VII (FVII), factor VIII (FVIII), and von Willebrand Factor antigen (vWF). Between-group differences were tested using linear mixed models with post-hoc between-group comparisons (Bonferroni-Holm corrected). Differences between baseline and shock were tested using paired t-tests. Significance was set at P < 0.05.

Results: GELO showed longer PCT at T60, compared with FWB and CRYST, and at T180, compared with all other groups. HES showed longer EXTEM CT at T60, compared with all other groups. HES showed lower INTEM and EXTEM MCF at T60 and lower INTEM MCF at T180, compared with FWB. Some plasma coagulation assays showed greater hypocoagulability with HES. Comparing shock to baseline, EXTEM CT, INTEM CFT, EXTEM CFT, PT, and FVIII significantly increased and PCT, INTEM CT, INTEM MCF, EXTEM MCF, EXTEM LI60, EXTEM TPI, FIBTEM MCF, APTT, fibrinogen, FVII, and vWF significantly decreased.

Conclusions: In dogs with hemorrhagic shock, volume replacement with GELO caused mild platelet dysfunction and HES was associated with coagulation changes consistent with hypocoagulability, beyond effects of hemodilution. Shock alone produced some evidence of hypocoagulability.

Ex vivo evaluation of the efficacy of canine fresh-frozen plasma thawed using a microwave plasma defroster

BACKGROUND

Commercial microwave plasma defrosters (MPDs) are used globally in human medicine to safely thaw fresh-frozen plasma (FFP), but this technology has never been tested in a veterinary setting. This study was undertaken to assess the efficacy of a commercial MPD for the rapid thawing of canine FFP.

STUDY DESIGN

Twenty-three units (twelve 120 mL and eleven 240 mL) of canine FFP were thawed using an MPD. Time-to-thaw and pre- and postthawing temperatures of the units were measured. Clotting factor activities (factors II, V, VII, VIII, IX, X, and von Willebrand factor), fibrinogen concentrations, prothrombin times, and activated partial thromboplastin times were measured.

KEY FINDINGS

The evaluated MPD effectively thaws plasma quickly for both 120 mL units (2.7 ± 0.08 min) and 240 mL units (3.9 ± 0.15 min) while maintaining clinically relevant activities of clotting factors and fibrinogen concentration. While some measurements of factor VIII activity fell below the reference interval, none fell below 40%. One 240 mL unit had von Willebrand factor activity <70%. There was no evidence of excessively heated plasma to indicate a safety concern.

SIGNIFICANCE

The MPD evaluated in this study provides a useful means to rapidly thaw canine FFP for correction of factor-deficient coagulopathy.

Identifying coagulopathies in the pathophysiology of cold stress syndrome in the Florida manatee Trichechus manatus latirostris

Cold stress syndrome (CSS) in the Florida manatee Trichechus manatus latirostris has been defined as morbidity and mortality resulting from prolonged exposure to water temperatures <20°C. The pathophysiology is described as multifactorial, involving nutritional, immunological and metabolic disturbances; however, the exact mechanisms are unknown. We hypothesized that thromboembolic complications contribute to the pathophysiology of CSS in addition to the previously described factors. During the winter of 2014-2015, 10 Florida manatees with clinical signs of CSS were presented to Lowry Park Zoo, Tampa, FL, USA. Thromboelastography (TEG) and coagulation panels were performed at admission. In addition, coagulation panel data from 23 retrospective CSS cases were included in the analyses. There were numerous differences between mean values of TEG and coagulation parameters for healthy manatees and those for CSS cases. Among TEG parameters, reaction time (R), clot formation time (K) and percentage of clot lysed after 30 min (LY30) values were significantly different (p < 0.05) between the 2 groups. CSS cases also had significantly higher mean D-dimer concentration and coagulation factor XI activity, prolonged mean activated partial thromboplastin time (aPTT) and significantly decreased mean antithrombin activity. These combined abnormalities include clinicopathologic criteria of disseminated intravascular coagulation, indicating an increased risk of thromboembolic disease associated with manatee CSS.

Progresses in understanding trauma-induced coagulopathy and the underlying mechanism

Trauma-induced coagulopathy (TIC) is a clinical syndrome caused by imbalance between clotting, anti-coagulation and fibrinolysis resulting from multiple pathological factors such as hemorrhage and tissue injury in the early stage of trauma, and is closely related to the outcome of trauma patients. It is proved in growing evidence that the endogenous coagulation disturbance in trauma itself is the activating factor of TIC, rather than dilution or other acquired coagulopathy. Therefore, a thorough understanding of the molecular mechanisms in the pathogenesis and progression is crucial for effective prevention and treatment in patients with TIC. This review focuses on transitions in the concept of TIC and mechanical progress.

Coagulation complications following trauma

Traumatic injury is one of the leading causes of death, with uncontrolled hemorrhage from coagulation dysfunction as one of the main potentially preventable causes of the mortality. Hypothermia, acidosis, and resuscitative hemodilution have been considered as the significant contributors to coagulation manifestations following trauma, known as the lethal triad. Over the past decade, clinical observations showed that coagulopathy may be present as early as hospital admission in some severely injured trauma patients. The hemostatic dysfunction is associated with higher blood transfusion requirements, longer hospital stay, and higher mortality. The recognition of this early coagulopathy has initiated tremendous interest and effort in the trauma community to expand our understanding of the underlying pathophysiology and improve clinical treatments. This review discusses the current knowledge of coagulation complications following trauma.

An in vitro comparison of the effects of voluven (6% hydroxyethyl starch 130/0.4) and hespan (6% hydroxyethyl starch 670/0.75) on measures of blood coagulation in canine blood

OBJECTIVE

To assess primary and secondary hemostasis following in vitro dilution of canine whole blood (WB) with hydroxyethyl starch (HES) 130/0.4 and HES 670/0.75.

DESIGN

In vitro experimental study.

SETTING

Private practice, teaching hospital.

ANIMALS

Twenty-five healthy dogs.

INTERVENTIONS

Each dog underwent venipuncture and 18 mL of venous blood was sampled once.

MEASUREMENTS AND MAIN RESULTS

Collected blood was separated in 4 aliquots. Aliquot A served as baseline sample. The remaining tubes of WB were diluted with 0.9% saline, HES 670/0.75 and HES 130/0.4 at a ratio of 1:5.5. Dilutional effects were evaluated using prothrombin time (PT), activated partial thromboplastin time (aPTT), packed cell volume (PCV), thromboelastography (TEG), and platelet closure time (Ct), which was measured using a platelet function analyzer (PFA). Clot strength (ie, G value) was calculated from measured TEG values. Significant increases in PT (P < 0.05) and aPTT (P < 0.05) were documented following WB dilution with saline. Dilution of WB with HES 670/0.75 and HES 130/0.4 resulted in significant hypocoagulable changes in K, MA and G (P < 0.05) compared to baseline and saline. When comparing saline to HES 670/0.75, both R and K values were significantly increased (P < 0.05). K value was significantly increased (P < 0.05) when comparing baseline to HES 130/0.4 and HES 670/0.75. Ct (P < 0.05) was significantly prolonged after WB dilution with HES solutions but not after saline.

CONCLUSIONS

Dilution of WB with HES 670/0.75 and HES 130/0.4 resulted in changes in primary and secondary hemostasis. Although there were small differences between saline and HES 670/0.75, no differences between HES solutions were evident in this small study. This may suggest there would be minimal increases in bleeding risk when either solution is administered to dogs at low doses. Clinical relevance of our findings requires further investigation.

Establishment of reference values for various coagulation tests in healthy Florida manatees (Trichechus manatus latirostris) and evaluation of coagulation in debilitated manatees during rehabilitation

OBJECTIVE

To establish reference ranges for coagulation parameters in healthy Florida manatees (Trichechus manatus latirostris) and compare results with those for debilitated manatees undergoing treatment at a rehabilitation facility.

DESIGN

Prospective study.

ANIMALS

29 healthy manatees and 45 debilitated manatees with various diseases.

PROCEDURES

Manatees considered healthy on the basis of results of physical examination, CBC, and serum biochemical analysis underwent coagulation testing including measurement of prothrombin time, partial thromboplastin time, D-dimer concentration, platelet count, and fibrinogen concentration to establish reference ranges. For comparison, a group of manatees undergoing rehabilitation was also tested, and the results were compared. Thromboelastography was also performed on some animals.

RESULTS

Values for D-dimer concentration were significantly higher in debilitated versus healthy animals. There was no significant difference for prothrombin time, partial thromboplastin time, platelet count, or fibrinogen concentration between groups. Thromboelastography was performed on 8 healthy animals.

CONCLUSIONS AND CLINICAL RELEVANCE

Reference ranges were established for various tests of coagulation that may assist clinicians during the initial evaluation and rehabilitation of Florida manatees. Future research to evaluate the effect of specific disease processes on the coagulation cascade is recommended.

Thromboelastography predictive of death in trauma patients

OBJECTIVES

To determine if thromboelastography (TEG) is predictive of patient outcomes following traumatic injury.

METHODS

A retrospective review of 131 patients with pelvic trauma admitted to a Level II trauma center was conducted over four years from 1 January 2009 to 31 December 2012. Patients were identified retrospectively from a prospectively collected database of acute pelvic trauma (n = 372). Eligible patients were identified from billing/coding data as having fractures of the acetabulum, iliac wing or sacral alae. Patients with incomplete TEG data were excluded (n = 241), as were patients with pathological fractures. TEG clotting variables and traditional clotting variables were recorded.

RESULTS

Evaluation of TEG data revealed 41 patients with abnormal clotting times (TEG R). TEG R > 6 was an independent risk factor for death (OR, 16; 95%CI 5.4-53; P = 0.0001). The death rate was 52% in patients with TEG R values ≥6 (n = 13/25). There was no significant association between traditional clotting markers and death rate.

CONCLUSIONS

TEG reaction time value, representing the time of initial clot formation, was the only hematologic marker predictive of mortality in patients with pelvic trauma. Delay in reaction time was associated with a significantly increased death rate, independent of injury severity. The death rate association was not observed with traditional markers of clotting. Future prospective studies may be warranted to determine the presentation and significance of TEG abnormalities when resuscitating patients with orthopaedic trauma.

Recent advances in disseminated intravascular coagulation: endothelial cells and fibrinolysis in sepsis-induced DIC

Endothelial cells are highly active, sensing and responding to signals from extracellular environments. They act as gatekeepers, mediating the recruitment and extravasation of proinflammatory leukocytes to the sites of tissue damage or infection. Endothelial cells participate in fibrinolysis by secreting tissue-type plasminogen activator, which converts plasminogen to active enzyme plasmin through constitutive and regulated pathways. Fibrinolysis systems and inflammation are tightly linked, as both responses are major host defense systems against both healing processes of tissue repair as well as pathogenic microorganisms. Endothelial cell dysfunction is one of the early signs of systemic inflammation, and it is a trigger of multiple organ failure in sepsis. The marked increase in plasminogen activator inhibitor-1 level causes fibrinolytic shutdown in endotoxemia or sepsis and is one of the most important predictors of multiple organ dysfunction during sepsis-induced disseminated intravascular coagulation (DIC). Leukocytes exhibit the first-line response to microorganisms. Leukocyte-derived elastase degrades cross-linked fibrin to yield molecular species distinct from those generated by plasmin. The alternative systems for fibrinolysis that interact with the plasminogen activator-plasmin systems may play crucial roles in the lysis of fibrin clots in sepsis-induced DIC.

Role of interventional radiology in trauma care: retrospective study from single trauma center experience

PURPOSE

Although interventional management is now regarded as essential in trauma care, the effect on clinical result remains uncertain. We conducted this retrospective study to figure out the role of interventional management in trauma care.

MATERIALS AND METHODS

Medical records of patients enrolled in the trauma database of our trauma center were reviewed for the period of January 2009 to December 2012. During this period, we have evaluated how many interventional procedures were conducted and the clinical effect of interventional procedure on trauma care.

RESULTS

Based on our institutional trauma database, medical records of 2017 patients were reviewed (male/female, 1475:542; mean age, 50.03 years). Their mean injury severity score was approximately 26.28. Among them, 111 patients have been treated with interventional procedure. The number of interventional procedures increased significantly over time, up to 15% (P < .005). During the same period, the overall survival rate did not show significant change. The survival rate of the patients, who have been treated with interventional procedures for traumatic vascular injury, was higher than possibility of survival from trauma injury severity score (86.4% vs 65.59%).

CONCLUSION

The need for interventional procedure in trauma care is increasing. Although interventional procedure could not affect the overall survival rate in trauma care, it can improve survival rate remarkably in patients with traumatic vascular injury.

Traumatic coagulopathy--part 2: Resuscitative strategies

OBJECTIVE

To discuss the current resuscitative strategies for trauma-induced hemorrhagic shock and acute traumatic coagulopathy (ATC).

ETIOLOGY

Hemorrhagic shock can be acutely fatal if not immediately and appropriately treated. The primary tenets of hemorrhagic shock resuscitation are to arrest hemorrhage and restore the effective circulating volume. Large volumes of isotonic crystalloids have been the resuscitative strategy of choice; however, data from experimental animal models and retrospective human analyses now recognize that large-volume fluid resuscitation in uncontrolled hemorrhage may be deleterious. The optimal resuscitative strategy has yet to be defined. In human trauma, implementing damage control resuscitation with damage control surgery for controlling ongoing hemorrhage, acidosis, and hypothermia; managing ATC; and restoring effective circulating volume is emerging as a more optimal resuscitative strategy. With hyperfibrinolysis playing an integral role in the manifestation of ATC, the use of antifibrinolytics (eg, tranexamic acid and aminocaproic acid) may also serve a beneficial role in the early posttraumatic period. Considering the sparse information regarding these resuscitative techniques in veterinary medicine, veterinarians are left with extrapolating information from human trials and experimental animal models.

DIAGNOSIS

Viscoelastic tests integrated with predictive scoring systems may prove to be the most reliable methods for early detection of ATC as well as for guiding transfusion requirements.

SUMMARY

Hemorrhage accounts for up to 40% of human trauma-related deaths and remains the leading cause of preventable death in human trauma. The exact proportion of trauma-related deaths due to exsanguinations in veterinary patients remains uncertain. Survivability depends upon achieving rapid definitive hemostasis, early attenuation of posttraumatic coagulopathy, and timely restoration of effective circulating volume. Early institution of damage control resuscitation in severely injured patients with uncontrolled hemorrhage has the ability to curtail posttraumatic coagulopathy and the exacerbation of metabolic acidosis and hypothermia and improve survival until definitive hemostasis is achieved.