Trauma-Induced Coagulopathy: Overview of an Emerging Medical Problem from Pathophysiology to Outcomes

Traumatic brain injury persistently increases the incidence of both ischemic and hemorrhagic strokes: Potential mechanisms

Traumatic brain injuries (TBI) significantly increase the risk of both ischemic and hemorrhagic strokes, with effects persisting for years after the initial injury. The mechanisms underlying this increased stroke risk are complex, multifactorial, and incompletely understood but likely include chronic cerebrovascular dysfunction, blood-brain barrier disruption, and inflammatory responses. Epidemiological studies consistently show that TBI is an independent risk factor for stroke, with more severe injuries associated with greater risk, especially for hemorrhagic strokes. Traditional risk factors for stroke, such as hypertension, poor diet, and sedentary lifestyle, further elevate the risk in TBI survivors. Modifiable lifestyle factors, such as improving sleep, increasing physical activity, and adopting heart-healthy diets, offer potential intervention points to mitigate stroke risk. Pharmacological considerations, including the use of antidepressants, anticoagulants, and statins, also influence stroke risk, particularly with regard to hemorrhagic complications. This review explores the pathophysiological mechanisms linking TBI and stroke, emphasizing the need for future research to identify specific biomarkers and imaging techniques to predict stroke vulnerability in TBI patients. Addressing the gaps in understanding, particularly regarding small vessel pathology, will be essential to developing targeted therapies for reducing stroke incidence in TBI survivors.

Tranexamic acid is associated with post-injury mortality in a resource-limited trauma system: Findings from the epidemiology and outcomes of prolonged trauma care cohort study

BACKGROUND

Injury-related deaths claim millions of lives annually, with severe hemorrhage a leading cause. This study assesses tranexamic acid (TXA) administered within 3 h post-injury on mortality in trauma patients.

STUDY DESIGN AND METHODS

We conducted secondary database analysis of EpiC, a multicenter, prospective cohort of trauma patients in South Africa. We compared mortality between severely injured patients at risk for traumatic hemorrhage receiving TXA within 3 h post-injury versus untreated patients. Inverse probability of treatment weighting adjusted for confounders, and multivariate logistic regression assessed 24-h mortality, with extended secondary outcome analyses.

RESULTS

Of 3607 analyzed patients, 502 received TXA within 3 h. TXA reduced 24-h mortality by 38% (marginal odds ratio [mOR], 0.62; 95% confidence interval [CI], 0.49-0.78) versus untreated patients. Similar reductions were observed for longer-term mortality. Subgroup analyses revealed reduced mortality when TXA was given within 2 h post-injury (mOR, 0.57; 95% CI, 0.45-0.73), doses of 1 g of TXA within 3 h (mOR, 0.73; 95% CI, 0.56-0.94), and those with the highest risk of hemorrhage (mOR, 0.40; 95% CI, 0.30-0.53). The 24-h mortality reduction was significant for patients with penetrating injury (mOR, 0.58; 95% CI, 0.43-0.78) but not for blunt injury patients. Sensitivity analyses confirmed the robustness of these findings, with TXA consistently reducing mortality odds by 28%-39% across subgroups.

DISCUSSION

Early TXA administration significantly reduced mortality in trauma patients, especially with penetrating injuries and those with the highest risk of hemorrhage. One-gram dosing was as effective as higher doses, and mortality reduction was notable when TXA was given within 2 h post-injury. These findings support TXA use in resource-limited trauma protocols.

A comprehensive overview of fixed-volume hemorrhage effects in New Zealand White rabbit models

Background

Hemorrhagic shock is a life-threatening condition resulting from acute blood loss, leading to compromised tissue perfusion and organ dysfunction. Currently, the guidelines for categorizing and managing hemorrhagic shock in pets are based on protocols developed for humans.

Aim

This study employed New Zealand White rabbits as an animal model to systematically evaluate the physiological and biochemical responses to fixed-volume hemorrhage, aiming to establish its role in inducing shock and significant physiological alterations.

Methods

A total of 21 New Zealand White rabbits, weighing 2-3 kg, were subjected to controlled hemorrhage by withdrawing 30%-35% of their total blood volume via the auricular artery using a 24-G IV catheter over 15 minutes. Parameters were assessed at baseline and 45 minutes post-induction.

Results

Hemorrhage induced significant increases in heart rate and respiratory rate, reflecting compensatory mechanisms to maintain perfusion during shock. The mean arterial pressure and blood pressure significantly declined, consistent with hemorrhagic shock. Oxygen saturation initially decreased but partially recovered over time. All hematological variables decreased. Coagulopathy was indicated by prolonged prothrombin time and activated partial thromboplastin time. Elevated lactate levels indicate a shift to anaerobic metabolism due to hypoxia. The increased levels of interleukin-10 and tumor necrosis factor-alpha suggested an adaptive anti-inflammatory response to mitigate excessive inflammation.

Conclusion

Fixed-volume hemorrhage in New Zealand White rabbits induces the physiological changes characteristic of hemorrhagic shock, providing valuable insights into the pathophysiological response to acute blood loss.

Management of Bleeding Diathesis in Elective and Orthopaedic Trauma: A Review

There is a general need among orthopaedic surgeons for practical advice on managing patients with bleeding disorders. Appropriate diagnosis and management of these disorders is paramount once discovered before, during, or after the patient's surgical course. Bleeding disorders disrupt the body's ability to control bleeding, commonly through platelet function and blood clotting. Normally, the vessel contracts and retracts once disruption of blood vessels occurs, limiting blood loss. Blood platelets adhere to exposed collagen, aggregate at the site, and obstruct blood loss. Because platelet aggregates are temporary, blood clotting is needed to back up the platelet plug and provide a milieu for the healing process that completes the hemostatic events. Disorders that interfere with any of these events can result in hemorrhage, drainage, or rebleeding. Bleeding disorders are a group of conditions, either hereditary or acquired, marked by abnormal or excessive bleeding and/or bruising. The most effective methods for assessing coagulation disorders include a detailed history and a series of blood tests. Clinical examination findings are notable but may be less specific. If a surgical patient has a bleeding disorder discovered preoperatively, postoperatively, or intraoperatively, treatments exist with medications, surgical management, interventional radiology procedures, and replacement therapy.

Correlation Between Low Platelet-to-Lymphocyte Ratio and High Mortality Rates in Adult Trauma Patients With Moderate-to-Severe Brain Injuries

Background: White blood cell (WBC) subtypes reflect immune and inflammatory conditions in patients. This study aimed to examine the association between the ratio of platelets to WBC subtypes and mortality outcomes in patients with moderate-to-severe traumatic brain injury (TBI). Method: The Trauma Registry System of the hospital was retrospectively reviewed to gather medical records of 2397 adult patients who were hospitalized from 2009 to 2020 and had moderate-to-severe TBI with a head abbreviated injury scale (AIS) score of 3 or higher. The monocyte-to-lymphocyte ratio (MLR), neutrophil-to-lymphocyte ratio (NLR), and platelet-to-lymphocyte ratio (PLR) were compared between the survivors (n = 2, 138) and nonsurvivors (n = 259). A multivariate logistic regression analysis was performed to investigate the independent effects of the univariate prognostic factors on mortality outcomes. The survival variations among the PLR subgroups were evaluated by the Kaplan-Meier survival analysis including a log-rank test. Results: The PLR of the deceased patients was considerably lower than that of the survivors (129.5 ± 130.1 vs. 153.2 ± 102.1, p < 0.001). However, no significant differences were observed in monocyte and neutrophil counts, MLR, or NLR between the deceased and survivor groups. A lower PLR was recognized as an independent risk factor for mortality (odds ratio: 1.26, 95% confidence interval: 1.06-1.51, p=0.010). The receiver operating characteristic (ROC) established PLR as the most strong predictor among the three ratios (area under the ROC curve = 0.627, sensitivity = 0.846, and specificity = 0.382, according to the cut-off value = 68.57). When the patient groups were divided by PLR quartile, the Kaplan-Meier analysis showed significantly worse survival in the lowest PLR quartile group (< 83.1) compared with the highest quartile group (≥ 189.1) (p < 0.001). Conclusion: Lower PLR is associated with greater mortality in adult patients with moderate-to-severe TBI. PLR may be a valuable measure for classifying mortality risk in this population.

Navigating Hemorrhagic Shock: Biomarkers, Therapies, and Challenges in Clinical Care

Hemorrhagic shock remains a leading cause of preventable death worldwide, with mortality patterns varying significantly based on injury mechanisms and severity. This comprehensive review examines the complex pathophysiology of hemorrhagic shock, focusing on the temporal evolution of inflammatory responses, biomarker utility, and evidence-based therapeutic interventions. The inflammatory cascade progresses through distinct phases, beginning with tissue injury and endothelial activation, followed by a systemic inflammatory response that can transition to devastating immunosuppression. Recent advances have revealed pattern-specific responses between penetrating and blunt trauma, necessitating tailored therapeutic approaches. While damage control resuscitation principles and balanced blood product administration have improved outcomes, many molecular targeted therapies remain investigational. Current evidence supports early hemorrhage control, appropriate blood product ratios, and time-sensitive interventions like tranexamic acid administration. However, challenges persist in biomarker validation, therapeutic timing, and implementation of personalized treatment strategies. Future directions include developing precision medicine approaches, real-time monitoring systems, and novel therapeutic modalities while addressing practical implementation barriers across different healthcare settings. Success in hemorrhagic shock management increasingly depends on integrating multiple interventions across different time points while maintaining focus on patient-centered outcomes.

[The golden approach to trauma. Which blood products are needed for optimization of prehospital trauma care?]

BACKGROUND

The golden hour of trauma denotes the critical first hour after severe injury where timely medical response is crucial, although scientific support for this time frame is inconsistent. This study emphasizes optimizing trauma care by tailoring treatment to the specific injury rather than focusing solely on the speed of treatment. The aim is to document the need for improvement in prehospital trauma care, particularly by the use of blood and coagulation products.

METHODS

After a pilot study, a purpose-designed online questionnaire targeted at German physicians and rescue service personnel was utilized to collect their views on general trauma care and specifically on the use of blood and coagulation products in prehospital settings. It also assessed the appropriateness of nine specific blood and coagulation products via a 5-point Likert scale. The percentages for each item were calculated for both physicians (n = 110) and rescue service personnel (n = 142) separately as well as an overall score to delineate patterns of agreement or disagreement.

RESULTS

The study reached 9837 individuals, whereby 371 initially answered the questionnaire and 252 participants from Germany were finally included in the statistical analysis. The majority of both physicians (89.1%) and rescue service personnel (90.8%) agreed on the need to improve prehospital trauma care, particularly through the use of blood and coagulation products. Specifically, 60.9% of physicians and 83.8% of rescue personnel supported the prehospital administration of these products. Red blood cell concentrates and fibrinogen were notably endorsed, with 76.2% and 67.1% approval, respectively, for their potential to enhance survival in patients with significant blood loss; however, opinions varied on other blood products.

CONCLUSION

The data demonstrated a readiness to change the trauma approach and confirmed that effective options are available. The utilization of certain products is supported by existing research, underlining the need for their practical implementation in preclinical settings. Here, the emphasis shifts from the isolated time components to the quality of care delivered in an optimized time interval. Ideally, timely and high-quality care should complement each other, leveraging all available therapeutic resources. This could lead to the development of a golden approach to trauma to optimize outcomes in trauma care.

Early Thrombocytopenia at Hospital Admission Predicts Mortality in Patients with Non-Isolated Severe Traumatic Brain Injury

Patients with severe traumatic brain injury (STBI) often experience an abnormal hemostasis that contributes to mortality and unfavorable neurological outcomes.

OBJECTIVES

We aimed to analyze epidemiologic, clinical, and laboratory factors associated with mortality in patients with STBI during the first 48 h after in-hospital admission.

METHODS

We performed an observational retrospective study of STBI patients with associated extracranial trauma [defined as Injury Severity Score (ISS) ≥ 16 with an Abbreviated Injury Scale (AIS) head and neck ≥ 3 and Glasgow Coma Scale (GCS) ≤ 8] admitted to a Level II trauma center over seven years (2015-2021). Patients were divided into two groups: survivors and dead. We assessed differences regarding demographics, trauma severity, hemodynamics, disability, need for surgery, length of stay, transfusions, need for massive transfusion protocol, and hemostatic laboratory parameters at different time points.

RESULTS

A total of 134 STBI patients were included. Patients who died were older, mostly men, and showed higher trauma severity and disability. Hemoglobin, platelets, and clotting parameters deteriorated after admission to the emergency department (ED) with significant differences between groups within the first 24 h after admission. Platelet count < 150 × 103/μL at ED arrival, GCS, and age were independent risk factors for mortality.

CONCLUSIONS

Older age, GCS, and platelet count at ED arrival were independent risk factors for mortality in STBI patients with associated extracranial trauma. Early thrombocytopenia < 150 × 103/μL at ED arrival may be used as a simple prognostic tool to early predict mortality between non-isolated STBI.

Biocompatible Liquid Embolic for the Treatment of Microvascular Hemorrhage

Persistent or recurrent bleeding from microvessels inaccessible for direct endovascular intervention is a major problem in medicine today. Here, an innovative catheter-directed liquid embolic (P-LE) is bioengineered for rapid microvessel embolization to treat small vessel hemorrhage. Tested in rodent, porcine, and canine animal models under normal and coagulopathic conditions, P-LE outperformed clinically used embolic materials in both survival and non-survival experiments, effectively occluding vessels as small as 40 microns with no signs of recanalization. P-LE occlusion is independent of the coagulation cascade, and its resistance to displacement is ≈ 8 times greater than systolic blood pressure. P-LE is also found to be biocompatible and x-ray visible and does not require polymerization or a chemical reaction to embolize. To simulate the clinical scenario, acute microvascular hemorrhage is created in the pig kidney, liver, or stomach; these are successfully treated with P-LE achieving immediate hemostasis. Furthermore, P-LE is found to be bactericidal to highly resistant patient-derived bacteria, suggesting that P-LE may also protect against infectious complications that may occur following embolization procedures. P-LE is safe, easy to use, and effective in treating -microvessel hemorrhage.

Mitochondrial dysfunction in platelets from severe trauma patients - A prospective case-control study

INTRODUCTION

Trauma-induced coagulopathy (TIC) refers to an abnormal coagulation process, an imbalance between coagulation and fibrinolysis due to several pathological factors, such as haemorrhage and tissue injury. Platelet activation and subsequent clot formation are associated with mitochondrial activity, suggesting a possible role for mitochondria in TIC. Comprehensive studies of mitochondrial dysfunction in platelets from severe trauma patients have not yet been performed.

METHODS

In this prospective case-control study, patients with severe trauma (ISS≥16) had venous blood samples taken at arrival to the Emergency Unit of a Level 1 Trauma Centre. Mitochondrial functional measurements (Oxygraph-2k, Oroboros) were performed to determine oxygen consumption in different respiratory states, the H2O2 production and extramitochondrial Ca2+ movements. In addition, standard laboratory and coagulation tests, viscoelastometry (ClotPro) and aggregometry (Multiplate) were performed. Measurements data were compared with age and sex matched healthy control patients.

RESULTS

Severe trauma patients (n = 113) with a median age of 38 years (IQR, 20-51), a median ISS of 28 (IQR, 20-48) met our inclusion criteria. Oxidative phosphorylation in platelet mitochondria from severe trauma patients significantly decreased compared to controls (34.7 ± 8.8 pmol/s/mL vs. 48.0 ± 19.7 pmol/s/mL). The mitochondrial H2O2 production significantly increased and greater endogenous Ca2+ release was found in the polytrauma group. Consistent with these results, clotting time (CT) increased while maximum clot firmness (MCF) decreased with the EX-test and FIB-test in severe trauma samples. Multiplate aggregometry showed significantly decreased ADP-test (38 ± 12 AUC vs. 112 ± 14 AUC) and ASPI test (78 ± 22 AUC vs. 84 ± 28 AUC) also tended to decrease in mitochondria of polytrauma patients as compared with controls. Significant strong correlation has been demonstrated between mitochondrial OxPhos and MCF while it was negatively correlated with ISS (R2=0.448, P˂0.05), INR, CT and lactate level of patients.

CONCLUSIONS

The present study revealed that severe trauma is associated with platelet mitochondrial dysfunction resulting in reduced ATP synthesis and impaired extramitochondrial Ca2+ movement. These factors are required for platelet activation, recruitment and clot stability likely thus, platelet mitochondrial dysfunction contributes to the development of TIC.

Effect of early administration of tetracosactide on mortality and host response in critically ill patients requiring rescue surgery: a sensitivity analysis of the STOPSHOCK phase 3 randomized controlled trial

BACKGROUND

Undifferentiated shock is recognized as a criticality state that is transitional in immune-mediated topology for casual risk of lethal microcirculatory dysfunction. This was a sensitivity analysis of a drug (tetracosactide; TCS10) targeting melanocortin receptors (MCRs) in a phase 3 randomized controlled trial to improve cardiovascular surgical rescue outcome by reversing mortality and hemostatic disorders.

METHODS

Sensitivity analysis was based on a randomized, two-arm, multicenter, double-blind, controlled trial. The Naïve Bayes classifier was performed by density-based sensitivity index for principal strata as proportional hazard model of 30-day surgical risk mortality according to European System for Cardiac Operative Risk Evaluation inputs-outputs in 100 consecutive cases (from August to September 2013 from Emilia Romagna region, Italy). Patients included an agent-based TCS10 group (10 mg, single intravenous bolus before surgery; n = 56) and control group (n = 44) and the association with cytokines, lactate, and bleeding-blood transfusion episodes with the prior-risk log-odds for mortality rate in time-to-event was analyzed.

RESULTS

Thirty-day mortality was significantly improved in the TCS10 group vs. control group (0 vs. 8 deaths, P < 0.0001). Baseline levels of interleukin (IL)-6, IL-10, and lactate were associated with bleeding episodes, independent of TCS10 treatment [odds ratio (OR) = 1.90, 95% confidence interval (CI) 1.39-2.79; OR = 1.53, 95%CI 1.17-2.12; and OR = 2.92, 95%CI 1.40-6.66, respectively], while baseline level of Fms-like tyrosine kinase 3 ligand (Flt3L) was associated with lower bleeding rates in TCS10-treated patients (OR = 0.31, 95%CI 0.11-0.90, P = 0.03). For every 8 TCS10-treated patients, 1 bleeding case was avoided. Blood transfusion episodes were significantly reduced in the TCS10 group compared to the control group (OR = 0.32, 95%CI 0.14-0.73, P = 0.01). For every 4 TCS10-treated patients, 1 transfusion case was avoided.

CONCLUSIONS

Sensitivity index underlines the quality target product profile of TCS10 in the runway of emergency casualty care. To introduce the technology readiness level in real-life critically ill patients, further large-scale studies are required.

TRIAL REGISTRATION

European Union Drug Regulating Authorities Clinical Trials Database (EudraCT Number: 2007-006445-41 ).

Using microfluidic shear to assess transfusion requirements in trauma patients

Background

Viscoelastic assays have widely been used for evaluating coagulopathies but lack the addition of shear stress important to in vivo clot formation. Stasys technology subjects whole blood to shear forces over factor-coated surfaces. Microclot formation is analyzed to determine clot area (CA) and platelet contractile forces (PCFs). We hypothesize the CA and PCF from this novel assay will provide information that correlates with trauma-induced coagulopathy and transfusion requirements.

Methods

Blood samples were collected on adult trauma patients from a single-institution prospective cohort study of high-level activations. Patient and injury characteristics, transfusion data, and outcomes were collected. Thromboelastography, coagulation studies, and Stasys assays were run on paired samples collected at admission. Stasys CA and PCFs were quantified as area under the curve calculations and maximum values. Normal ranges for Stasys assays were determined using healthy donors. Data were compared using Kruskal-Wallis tests and simple linear regression.

Results

From March 2021 to January 2023, 108 samples were obtained. Median age was 37.5 (IQR 27.5-52) years; patients were 77% male. 71% suffered blunt trauma, 26% had an Injury Severity Score of ≥25. An elevated international normalized ratio significantly correlated with decreased cumulative PCF (p=0.05), maximum PCF (p=0.05) and CA (p=0.02). Lower cumulative PCF significantly correlated with transfusion of any products at 6 and 24 hours (p=0.04 and p=0.05) as well as packed red blood cells (pRBCs) at 6 and 24 hours (p=0.04 and p=0.03). A decreased maximum PCF showed significant correlation with receiving any transfusion at 6 (p=0.04) and 24 hours (p=0.02) as well as transfusion of pRBCs, fresh frozen plasma, and platelets in the first 6 hours (p=0.03, p=0.03, p=0.03, respectively).

Conclusions

Assessing coagulopathy in real time remains challenging in trauma patients. In this pilot study, we demonstrated that microfluidic approaches incorporating shear stress could predict transfusion requirements at time of admission as well as requirements in the first 24 hours.

Level of evidence

Level II.

Antidote vs. unspecific hemostatic agents for the management of direct oral anticoagulant-related bleeding in trauma

PURPOSE OF REVIEW

The advent of direct oral anticoagulants (DOACs) marks a significant milestone in anticoagulant treatment. However, DOACs can exacerbate bleeding, which is challenging for the treating clinician, especially when combined with traumatic injury.

RECENT FINDINGS

In major bleeding associated with DOACs, rapid reversal of the anticoagulant effects is crucial. Recent observational and nonrandomized interventional trials have demonstrated the effectiveness of the specific antidotes andexanet alfa and idarucizumab as well as the unspecific prothrombin complex concentrates (PCCs) to counteract the anticoagulant effects of DOACs. The European Society of Anaesthesiology and Intensive Care guideline for severe perioperative bleeding and the European trauma guideline propose divergent recommendations for the use of andexanet alfa and PCC to obtain hemostasis in Factor Xa inhibitor-related bleeding. The conflicting recommendations are due to limited evidence from clinical studies and the potential increased risk of thromboembolic complications after the administration of andexanet. Regarding dabigatran-associated major bleeding, both guidelines recommend the specific reversal agent idarucizumab as first-line therapy.

SUMMARY

Current guidelines recommend specific antidots and PCCs in DOAC-related major bleeding. Prospective randomized trials comparing specific vs. nonspecific hemostatic agents in the perioperative setting are needed to evaluate the effectiveness and safety of the hemostatic agents.

Analysis of risk factors for trauma-induced coagulopathy in elderly major trauma patients

BACKGROUND

Trauma-induced coagulopathy (TIC) due to serious injuries significantly leads to increased mortality and morbidity among elderly patients. However, the risk factors of TIC are not well elucidated. This study aimed to explore the risk factors of TIC in elderly patients who have major trauma.

METHODS

In this retrospective study, the risk factors for TIC in elderly trauma patients at a single trauma center were investigated between January 2015 and September 2020. The demographic information including gender, age, trauma parts, injury severity, use of blood products, use of vasopressors, need of emergency surgery, duration of mechanical ventilation, length of stay in the intensive care unit (ICU) and hospital, and clinical outcomes were extracted from electric medical records. Multivariate logistic regression analysis was performed to differentiate risk factors, and the performance of the model was evaluated using receiver operating characteristics (ROC) curves.

RESULTS

Among the 371 elderly trauma patients, 248 (66.8%) were male, with the age of 72.5 ± 6.8 years, median injury severity score (ISS) of 24 (IQR: 17-29), and Glasgow coma score (GCS) of 14 (IQR: 7-15). Of these patients, 129 (34.8%) were diagnosed with TIC, whereas 242 (65.2%) were diagnosed with non-TIC. The severity scores such as ISS (25 [20-34] vs. 21 [16-29], P<0.001) and shock index (SI), (0.90±0.66 vs. 0.58 ± 0.18, P<0.001) was significantly higher in the TIC group than in the non-TIC group. Serum calcium levels (1.97±0.19 mmol/L vs. 2.15±0.16 mmol/L, P<0.001), fibrinogen levels (1.7±0.8 g/L vs. 2.8±0.9 g/L, P<0.001), and base excess (BE, -4.9±4.6 mmol/L vs. -1.2 ± 3.1 mmol/L, P<0.001) were significantly lower in the TIC group than in the non-TIC group. Multivariate logistic regression analysis revealed that ISS>16 (OR: 3.404, 95%CI: 1.471-7.880; P=0.004), SI>1 (OR: 5.641, 95%CI: 1.700-18.719; P=0.005), low BE (OR: 0.868, 95%CI: 0.760-0.991; P=0.037), hypocalcemia (OR: 0.060, 95%CI: 0.009-0.392; P=0.003), and hypofibrinogenemia (OR: 0.266, 95%CI: 0.168-0.419; P<0.001) were independent risk factors for TIC in elderly trauma patients. The AUC of the prediction model included all these risk factors was 0.887 (95%CI: 0.851-0.923) with a sensitivity and specificity of 83.6% and 82.6%, respectively.

CONCLUSION

Higher ISS (more than 16), higher SI (more than 1), acidosis, hypocalcemia, and hypofibrinogenemia emerged as independent risk factors for TIC in elderly trauma patients.

Sensitivity and specificity of thromboelastography for hyperfibrinolysis: Comparison of TEG 5000 and TEG 6S CK LY30 systems

OBJECTIVES

The sensitivity and specificity of clot lysis at 30 minutes after maximum clot strength (LY30), as measured by thromboelastography (TEG), for clinically significant hyperfibrinolysis have not been compared across the 2 US Food and Drug Administration-approved instruments (the TEG 5000 and TEG 6s [Haemonetics]).

METHODS

We performed a retrospective, single-center analysis of these 2 instruments using the kaolin (CK) reagent.

RESULTS

Local verification studies showed that the TEG 5000 and TEG 6s CK LY30 upper limits of normal (ULNs) were distinct (5.0% and 3.2%, respectively). Retrospective analysis of patient data showed that abnormal LY30 was 6 times more prevalent with the TEG 6s than with the TEG 5000 instrument. LY30 was a significant predictor of mortality with both instruments (TEG 6s: receiver operating characteristic [ROC] area under the curve [AUC] = 0.836, P ≤ .0001; TEG 5000: ROC AUC = 0.779, P = .028). The optimal LY30 cut point was determined based on these mortality data for each instrument. The TEG 6s showed superior mortality prediction than the TEG 5000 at lower LY30 levels (≥10%), with likelihood ratios of 8.22 and 2.62 for the TEG 6s and TEG 5000, respectively. Patients with a TEG 6s CK LY30 of 10% or higher were significantly more likely to die, receive cryoprecipitate, receive transfusions, or receive massive transfusion than patients with a TEG 6s LY30 of 3.3% to 9.9% (all P < .01). Patients with a TEG 5000 LY30 of 17.1% or higher were significantly more likely to die or use cryoprecipitate (P < .05); transfusion and massive transfusion protocol were not significantly different. Whole blood spiking studies showed that 70 ng/mL tissue plasminogen activator (tPA) achieved an average LY30 of approximately 10% for both instruments.

CONCLUSIONS

CK LY30 above the ULN is a sensitive but not specific cutoff for hyperfibrinolysis. At least moderately elevated CK LY30 carries more clinical portent on the TEG 6s instrument than on the TEG 5000. These TEG instruments are not sensitive to low concentrations of tPA.

Effects of Different Crystalloid Fluids on Renal Tissue in an Experimental Model of Hemorrhagic Shock

Objective

The type of fluid that should be used in uncontrollable hemorrhages remains an area of research. This study was designed to compare the effects of resuscitation with Ringer's lactate (RL) solution versus a normal saline (NS) solution on hemodynamics, renal tissue histopathology, coagulation, and apoptosis in a rat model of hemorrhagic shock.

Methods

The study employed groups designated as the control, hemorrhage, NS, and RL groups. Heart rate, mean arterial pressure, and respiratory rate were monitored. Annexin A5 values were assayed, rotational thromboelastometry analysis was performed, and excised kidney tissue samples were histopathologically analyzed.

Results

Blood pressure levels were found to be significantly higher in the control group than those measured in the other groups. While the clotting time (CT) and clot formation time (CFT) in the hemorrhage group were significantly longer than those in the control and RL groups, the CT and CFT measured in the control group were significantly shorter compared to the RL group. The mean Annexin A5 level was in the hemorrhage group, which was significantly higher compared to the other groups. In the renal histopathological evaluation, the scores of proximal tubular injury, distal renal tubular injury, and interstitial renal tubular injury were found to be significantly lower in the control group compared to the other groups.

Conclusion

This study demonstrated that NS or RL can be used safely to improve the hemodynamic symptoms resulting from hemorrhagic shock as a means to reduce apoptosis, and to decrease findings in favor of coagulopathy in bedside coagulation tests during the early stages of hemorrhagic shock until the time of starting a blood transfusion.

The Use of Large Animal Models in Trauma and Bleeding Studies

BACKGROUND

 Major trauma often results in significant bleeding and coagulopathy, posing a substantial clinical burden. To understand the underlying pathophysiology and to refine clinical strategies to overcome coagulopathy, preclinical large animal models are often used. This review scrutinizes the clinical relevance of large animal models in hemostasis research, emphasizing challenges in translating findings into clinical therapies.

METHODS

 We conducted a thorough search of PubMed and EMBASE databases from January 1, 2010, to December 31, 2022. We used specific keywords and inclusion/exclusion criteria centered on large animal models.

RESULTS

 Our review analyzed 84 pertinent articles, including four animal species: pigs, sheep, dogs, and nonhuman primates (NHPs). Eighty-five percent of the studies predominantly utilized porcine models. Meanwhile, sheep and dogs were less represented, making up only 2.5% of the total studies. Models with NHP were 10%. The most frequently used trauma models involved a combination of liver injury and femur fractures (eight studies), arterial hemorrhage (seven studies), and a combination of hemodilution and liver injury (seven studies). A wide array of coagulation parameters were employed to assess the efficacy of interventions in hemostasis and bleeding control.

CONCLUSIONS

 Recognizing the diverse strengths and weaknesses of large animal models is critical for trauma and hemorrhage research. Each model is unique and should be chosen based on how well it aligns with the specific scientific objectives of the study. By strategically considering each model's advantages and limitations, we can enhance our understanding of trauma and hemorrhage pathophysiology and further advance the development of effective treatments.

Experimental Models of Traumatic Injuries: Do They Capture the Coagulopathy and Underlying Endotheliopathy Induced by Human Trauma?

Trauma-induced coagulopathy (TIC) is a major cause of morbidity and mortality in patients with traumatic injury. It describes the spectrum of coagulation abnormalities that occur because of the trauma itself and the body's response to the trauma. These coagulation abnormalities range from hypocoagulability and hyperfibrinolysis, resulting in potentially fatal bleeding, in the early stages of trauma to hypercoagulability, leading to widespread clot formation, in the later stages. Pathological changes in the vascular endothelium and its regulation of haemostasis, a phenomenon known as the endotheliopathy of trauma (EoT), are thought to underlie TIC. Our understanding of EoT and its contribution to TIC remains in its infancy largely due to the scarcity of experimental research. This review discusses the mechanisms employed by the vascular endothelium to regulate haemostasis and their dysregulation following traumatic injury before providing an overview of the available experimental in vitro and in vivo models of trauma and their applicability for the study of the EoT and its contribution to TIC.

Identifying predictive factors for mortality in patients with TBI at a neurosurgery department

Traumatic brain injury (TBI) can have severe consequences in most cases. Many therapeutic and neurosurgical strategies have been improved to optimize patient outcomes. However, despite adequate surgery and intensive care, death can still occur during hospitalization. TBI often results in protracted hospital stays in neurosurgery departments, indicating the severity of brain injury. Several factors related to TBI are predictive of longer hospital stays and in-hospital mortality rates. This study aimed to identify predictive factors for intrahospital days of death due to TBI. This was a longitudinal, retrospective, analytical, observational study that included 70 TBI-related deaths admitted to the Neurosurgery Clinic in Cluj-Napoca for a period of four years (January 2017 to December 2021) using a cohort model. We identified some clinical data related to intrahospital death after TBI. The severity of TBI was classified as mild (n=9), moderate(n=13), and severe (n=48) and was associated with significantly fewer hospital days (p=0.009). Patients with associated trauma, such as vertebro-medullary or thoracic trauma, were more likely to die after a few days of hospitalization (p=0.007). Surgery applied in TBI was associated with a higher median number of days until death compared to conservative treatment. A low GCS was an independent predictive factor for early intrahospital mortality in patients with TBI. In conclusion, clinical factors such as the severity of injury, low GCS, and polytrauma are predictive of early intrahospital mortality. Surgery was associated with prolonged hospitalization.

A narrative review of damage control resuscitation for paediatric trauma patients in Iraq and Afghanistan from 2001 to 2016

Introduction

Requirement for blood transfusion in the injured paediatric civilian population is rare. Therefore, a substantial evidence base underpinning damage control resuscitation (DCR) in paediatric patients is lacking. Published outcome data originating from Iraq and Afghanistan offer a unique opportunity to study large cohorts of children who received DCR. It is hoped that by collating the data, this review will inform pre-deployment medical training and support the development of paediatric specific DCR guidelines, which can be used in all trauma environments.

Methodology

A comprehensive search of the literature was conducted using online databases, grey literature searching and screening of reference lists. Papers discussing blood product, crystalloid or tranexamic acid (TXA) administration in paediatric patients injured in Iraq and Afghanistan from 2001to present were included.

Results

Eighteen papers were included – all were retrospective studies of data from military trauma databases. Most children that received massive transfusion were male (73.4%), injured in Afghanistan (69.9%) by explosives (60.4%) with a median age of 9 years. A definition of paediatric massive transfusion of 40 ml/kg of all blood products within 24 h was developed. Massive transfusion rates were high (15.7% of children). Whole blood administration occurred in 4% of patients requiring blood transfusions. Low crystalloid volumes in combination with balanced blood product ratios were associated with improved survival, along with the use of whole blood and TXA.

Conclusion

The review offers insight into the paediatric population likely to require DCR and the optimal DCR strategies to be used in their management.

The hemostatic profile of cold-stored whole blood from non-greyhound and greyhound dogs over 42 days

Objectives

To compare the hemostatic characteristics of cold-stored whole blood (CSWB) from non-greyhound dogs (NGD) and greyhound dogs (GD) over 42 days of storage, notably, platelet closure time (PCT) (NGD only), manual platelet count (PLT) (GD only), ellagic acid (INTEM) and tissue factor activated (EXTEM) rotational thromboelastometry, prothrombin (PT) and activated partial thromboplastin time (aPTT), fibrinogen concentration (FIB), and the activities of factors (F) FII, FV, FVII, FVIII, FIX, FX, FXIII antigen (FXIII:Ag), and von Willebrand factor antigen (vWF:Ag).

Design

Whole blood from 10 NGD and 10 GD, was refrigerated in CPD blood bags at 4°C for 42 days. Blood was analyzed before refrigeration (day 0) and at day 1 (d1), 3, 5, 7, 10, 14, 17, 21, 24, 28, 31, 35, 38, and 42. Multivariate linear mixed effects models were created to evaluate coagulation parameters over time and compare NGD and GD. Data are summarized as estimated marginal means with 95% confidence intervals. Significance was set at P < 0.05.

Results

The PCT for all NGD CSWB was above the device limit by d7. The PLT for GD CSWB did not change during storage. The mean alpha-angle for INTEM and EXTEM decreased to <50% of baseline at d38 and d31 for NGD, and d31 and d17 for GD CSWB. The mean maximum clot firmness (MCF) for INTEM and EXTEM reduced to <50% of baseline at d42 and d28 for both GD and NGD. PT and aPTT for NGD and GD increased over time. For NGD CSWB, the mean FVIII and vWF:Ag activities decreased to <50% of baseline at d7 and d28, respectively, and FIB reached 0.982 g/dL by d24. For GD CSWB, FVIII, FXIII:Ag and FV activities decreased to <50% of baseline by d3, d38, and d38, respectively, and FIB was 0.982 g/dL at baseline. Alpha-angle and MCF for both INTEM and EXTEM, and activities for FII, FV, FIX, FXIII:Ag were significantly lower, and vWF:Ag was significantly higher overall in GD CSWB compared with NGD. A significant difference in the pattern of change over time was detected between NGD and GD in EXTEM alpha-angle, INTEM and EXTEM MCF, FII, and FVIII activities.

Conclusions

The in vitro viscoelastic parameters of GD and NGD CSWB declines over 42 days, but numerous hemostatic parameters (INTEM and EXTEM alpha-angle and MCF, activity of FII, FV, FV, FVII, FIX, FX, FXIII:Ag, vWF:Ag, and FIB) remain within 50% of baseline for more than 14 days. CSWB from GD compared to NGD has reduced hemostatic activity overall, but a similar pattern of decline for most parameters over time.

Association of Extravascular Leakage on Computed Tomography Angiography with Fibrinogen Levels at Admission in Patients with Traumatic Brain Injury

Extravascular leakage on computed tomography (CT) angiography in patients with traumatic brain injury (TBI) is associated with hematoma expansion, functional prognosis, subsequent surgery, and death. Fresh frozen plasma (FFP) administration is often necessary to treat coagulation disorders associated with TBI. This study aimed to determine the relationship between the presence of extravascular leakage on contrast-enhanced head CT, fibrinogen level at admission, and FFP administration in patients with TBI. The medical records of patients with TBI ≥18 years of age referred to our hospital between January 2010 and December 2020 were examined retrospectively. Patients who underwent contrast-enhanced CT immediately after admission were selected, and the presence or absence of extravascular leakage, fibrinogen level at admission, and percentage of patients who required FFP administration within 24 h of admission were examined; 172 patients were included. Multi-variable linear regression analysis was performed to determine the effects of contrast extravasation on fibrinogen levels at admission and was adjusted for age, sex, systolic blood pressure, time from injury to admission, Marshall CT score, Glasgow Coma Scale score at admission, Injury Severity Score, and need for emergency surgery; the regression coefficient was -19.8. The effect of extravasation on FFP administration within 24 h of admission was analyzed using logistic regression while adjusting for age, systolic blood pressure, Marshall CT score, need for emergency surgery, and fibrinogen level at admission. The odds ratio of contrast extravasation was 7.08 after adjustment. Extravascular leakage is associated with fibrinogen levels at admission and FFP administration within 24 h of admission.

Antifibrinolytics in the treatment of traumatic brain injury

PURPOSE OF REVIEW

Traumatic brain injury (TBI) is a leading cause of trauma-related deaths, and pharmacologic interventions to limit intracranial bleeding should improve outcomes. Tranexamic acid reduces mortality in injured patients with major systemic bleeding, but the effects of antifibrinolytic drugs on outcomes after TBI are less clear. We therefore summarize recent evidence to guide clinicians on when (not) to use antifibrinolytic drugs in TBI patients.

RECENT FINDINGS

Tranexamic acid is the only antifibrinolytic drug that has been studied in patients with TBI. Several recent studies failed to conclusively demonstrate a benefit on survival or neurologic outcome. A large trial with more than 12 000 patients found no significant effect of tranexamic acid on head-injury related death, all-cause mortality or disability across the overall study population, but observed benefit in patients with mild to moderate TBI. Observational evidence signals potential harm in patients with isolated severe TBI.

SUMMARY

Given that the effect of tranexamic acid likely depends on a variety of factors, it is unlikely that a 'one size fits all' approach of administering antifibrinolytics to all patients will be helpful. Tranexamic acid should be strongly considered in patients with mild to moderate TBI and should be avoided in isolated severe TBI.

Association between Functional Parameters of Coagulation and Conventional Coagulation Tests in the Setting of Fluid Resuscitation with Balanced Crystalloid or Gelatine: A Secondary Analysis of an In Vivo Prospective Randomized Crossover Study

Functional point-of-care tests (POCTs) have evolved into useful tools for diagnosing disorders of blood coagulation and fibrinolysis. We aimed to describe the in vivo association between standard and functional parameters of coagulation and fibrinolysis in the setting of acute hemodilution induced by an infusion of balanced crystalloid or synthetic gelatine solutions. This prospective randomized crossover in vivo study included healthy male volunteers aged 18–30 years. Enrolled participants were randomly assigned to receive either the Optilyte^® or Geloplasma^® infusion. Laboratory analysis included conventional coagulation parameters and rotational thromboelastometry (ROTEM) assays. A total of 25 healthy Caucasian males were included. ROTEM viscoelastic assays presented moderate to strong correlations with conventional coagulation tests, regardless of the fluid type utilized. Irrespectively of the extent of hemodilution, significant correlations remained unaffected. The strongest associations were found between the ROTEM clot formation and clot strength and the fibrinogen concentration and platelet count, and between the ROTEM clotting time and the APTT and PT. This in vivo experimental study in healthy male volunteers demonstrated that ROTEM may be used as a credible alternative to standard laboratory tests to assess blood coagulation and fibrinolysis in the setting of fluid resuscitation with both crystalloid and colloid solutions. The study was registered online in the ClinicalTrials.gov database (NCT05148650).

Pathophysiology and Therapy of High-Altitude Sickness: Practical Approach in Emergency and Critical Care

High altitude can be a hostile environment and a paradigm of how environmental factors can determine illness when human biological adaptability is exceeded. This paper aims to provide a comprehensive review of high-altitude sickness, including its epidemiology, pathophysiology, and treatments. The first section of our work defines high altitude and considers the mechanisms of adaptation to it and the associated risk factors for low adaptability. The second section discusses the main high-altitude diseases, highlighting how environmental factors can lead to the loss of homeostasis, compromising important vital functions. Early recognition of clinical symptoms is important for the establishment of the correct therapy. The third section focuses on high-altitude pulmonary edema, which is one of the main high-altitude diseases. With a deeper understanding of the pathogenesis of high-altitude diseases, as well as a reasoned approach to environmental or physical factors, we examine the main high-altitude diseases. Such an approach is critical for the effective treatment of patients in a hostile environment, or treatment in the emergency room after exposure to extreme physical or environmental factors.

Blood Transfusion Reactions-A Comprehensive Review of the Literature including a Swiss Perspective

Blood transfusions have been the cornerstone of life support since the introduction of the ABO classification in the 20th century. The physiologic goal is to restore adequate tissue oxygenation when the demand exceeds the offer. Although it can be a life-saving therapy, blood transfusions can lead to serious adverse effects, and it is essential that physicians remain up to date with the current literature and are aware of the pathophysiology, initial management and risks of each type of transfusion reaction. We aim to provide a structured overview of the pathophysiology, clinical presentation, diagnostic approach and management of acute transfusion reactions based on the literature available in 2022. The numbers of blood transfusions, transfusion reactions and the reporting rate of transfusion reactions differ between countries in Europe. The most frequent transfusion reactions in 2020 were alloimmunizations, febrile non-hemolytic transfusion reactions and allergic transfusion reactions. Transfusion-related acute lung injury, transfusion-associated circulatory overload and septic transfusion reactions were less frequent. Furthermore, the COVID-19 pandemic has challenged the healthcare system with decreasing blood donations and blood supplies, as well as rising concerns within the medical community but also in patients about blood safety and transfusion reactions in COVID-19 patients. The best way to prevent transfusion reactions is to avoid unnecessary blood transfusions and maintain a transfusion-restrictive strategy. Any symptom occurring within 24 h of a blood transfusion should be considered a transfusion reaction and referred to the hemovigilance reporting system. The initial management of blood transfusion reactions requires early identification, immediate interruption of the transfusion, early consultation of the hematologic and ICU departments and fluid resuscitation.

Dysbarism: An Overview of an Unusual Medical Emergency

Dysbarism is a general term which includes the signs and symptoms that can manifest when the body is subject to an increase or a decrease in the atmospheric pressure which occurs either at a rate or duration exceeding the capacity of the body to adapt safely. In the following review, we take dysbarisms into account for our analysis. Starting from the underlying physical laws, we will deal with the pathologies that can develop in the most frequently affected areas of the body, as the atmospheric pressure varies when acclimatization fails. Manifestations of dysbarism range from itching and minor pain to neurological symptoms, cardiac collapse, and death. Overall, four clinical pictures can occur: decompression illness, barotrauma, inert gas narcosis, and oxygen toxicity. We will then review the clinical manifestations and illustrate some hints of therapy. We will first introduce the two forms of decompression sickness. In the next part, we will review the barotrauma, compression, and decompression. The last three parts will be dedicated to gas embolism, inert gas narcosis, and oxygen toxicity. Such an approach is critical for the effective treatment of patients in a hostile environment, or treatment in the emergency room after exposure to extreme physical or environmental factors.

Mitochondrial dysfunction in trauma-related coagulopathy - Is there causality? - Study protocol for a prospective observational study

Hemorrhage control often poses a great challenge for clinicians due to trauma-induced coagulopathy (TIC). The pathogenesis of TIC is not completely revealed; however, growing evidence attributes a central role to altered platelet biology. The activation of thrombocytes and subsequent clot formation are highly energetic processes being tied to mitochondrial activity, and the inhibition of the electron transport chain (ETC) impedes on thrombogenesis, suggesting the potential role of mitochondria in TIC. Our present study protocol provides a guide to quantitatively characterize the derangements of mitochondrial functions in TIC. One hundred eleven severely injured (Injury Severity Score ≥16), bleeding trauma patients with an age of 18 or greater will be included in this prospective observational study. Patients receiving oral antiplatelet agents including cyclooxygenase-1 or adenosine diphosphate receptor inhibitors (aspirin, clopidogrel, prasugrel, and ticagrelor) will be excluded from the final analysis. Hemorrhage will be confirmed and assessed with computer tomography. Conventional laboratory markers of hemostasis such as prothrombin time and international normalized ratio (INR) will be measured and rotational thromboelastometry (ROTEM) will be performed directly upon patient arrival. Platelets will be isolated from venous blood samples and subjected to high-resolution fluororespirometry (Oxygraph-2k, Oroboros Instruments, Innsbruck, Austria) to evaluate the efficacy of mitochondrial respiration. Oxidative phosphorylation (OxPhos), coupling of the ETC, mitochondrial superoxide formation, mitochondrial membrane potential changes and extramitochondrial Ca2+-movement will be recorded. The association between OxPhos capacity of platelet mitochondria and numerical parameters of ROTEM aggregometry will constitute our primary outcome. The relation between OxPhos capacity and results of viscoelastic assays and conventional markers of hemostasis will serve as secondary outcomes. The association of the OxPhos capacity of platelet mitochondria upon patient arrival to the need for massive blood transfusion (MBT) and 24-hour mortality will constitute our tertiary outcomes. Mitochondrial dysfunction and its importance in TIC in are yet to be assessed for the deeper understanding of this common, life-threatening condition. Disclosure of mitochondria-mediated processes in thrombocytes may reveal new therapeutic targets in the management of hemorrhaging trauma patients, thereby leading to a reduction of potentially preventable mortality. The present protocol was registered to ClinicalTrials.gov on 12 August 2021, under the reference number NCT05004844.

Mild Head Trauma (MHT) and Antiplatelet Therapy. Reply to Lorenzati et al. Comment on "Savioli et al. Mild Head Trauma: Is Antiplatelet Therapy a Risk Factor for Hemorrhagic Complications? Medicina 2021, 57, 357"

We read your data with interest, and we truly appreciate the similar experience [...].

Association of Platelets and White Blood Cells Subtypes with Trauma Patients' Mortality Outcome in the Intensive Care Unit

Background: White blood cell (WBC) subtypes have been suggested to reflect patients’ immune-inflammatory status. Furthermore, the derived ratio of platelets and WBC subtypes, including monocyte-to-lymphocyte ratio (MLR), neutrophil-to-lymphocyte ratio (NLR), and platelet-to-lymphocyte ratio (PLR), is proposed to be associated with patient outcome. Therefore, this study aimed to identify the association of platelets and white blood cells subtypes with the mortality outcome of trauma patients in the intensive care unit (ICU). Method: The medical information from 2854 adult trauma patients admitted to the ICU between 1 January 2009 and 31 December 2019 were retrospectively retrieved from the Trauma Registry System and classified into two groups: the survivors group (n = 2524) and the death group (n = 330). The levels of monocytes, neutrophils, lymphocytes, platelets, and blood-drawn laboratory data detected upon patient arrival to the emergency room and the derived MLR, NLR, and PLR were calculated. Multivariate logistic regression analysis was used to determine the independent effects of univariate predictive variables on mortality occurrence. Result: The results revealed the patients who died had significantly lower platelet counts (175,842 ± 61,713 vs. 206,890 ± 69,006/μL, p < 0.001) but higher levels of lymphocytes (2458 ± 1940 vs. 1971 ± 1453/μL, p < 0.001) than the surviving patients. However, monocyte and neutrophil levels were not significantly different between the death and survivor groups. Moreover, dead patients had a significantly lower PLR than survivors (124.3 ± 110.3 vs. 150.6 ± 106.5, p < 0.001). However, there was no significant difference in MLR or NLR between the dead patients and the survivors. Multivariate logistic regression revealed that male gender, old age, pre-existing hypertension, coronary artery disease and end-stage renal disease, lower Glasgow Coma Scale (GCS), higher Injury Severity Score (ISS), higher level of lymphocytes and lower level of red blood cells and platelets, longer activated partial thromboplastin time (aPTT), and lower level of PLR were independent risk factors associated with higher odds of trauma patient mortality outcome in the ICU. Conclusion: This study revealed that a higher lymphocyte count, lower platelet count, and a lower PLR were associated with higher risk of death in ICU trauma patients.