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Diagnosis, Treatment and Management of Trauma-Induced Coagulation Disorder: Current Updates...
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Diagnosis, Treatment and Management of Trauma-Induced Coagulation Disorder: Current Updates and Perspectives

A special issue of Journal of Clinical Medicine (ISSN 2077-0383). This special issue belongs to the section "Hematology".

Deadline for manuscript submissions: closed (28 July 2022) | Viewed by 16501

Special Issue Editors

Dr. Herbert Schöchl

E-Mail Website
Guest Editor
AUVA Trauma Center Salzburg, Salzburg, Austria
Interests: trauma-induced coagulopathy; viscoelastic testing in trauma; massive transfusion strategies; mortality prediction; trauma and anticoagulants
Prof. Dr. Oliver Grottke

E-Mail Website
Guest Editor
Department of Anesthesiology, University Hospital RWTH Aachen, Aachen, Germany
Interests: coagulation; haemostasis; platelets; anesthesia; thrombosis; hemostasis; blood coagulation; platelet activation; blood transfusion; blood disorders
Prof. Dr. Marc Maegele

E-Mail Website
Guest Editor
Department of Trauma and Orthopedic Surgery, University of Witten/Herdecke, Cologne-Merheim Medical Center (CMMC), Ostmerheimerstr. 200, D-51109 Cologne, Germany
Interests: acute coagulopathy of trauma; multiple trauma

Special Issue Information

Dear Colleagues,

Exsanguination in severely injured trauma patients continues to be a significant cause of early in-hospital mortality. Many of these patients suffer from trauma-induced coagulopathy (TIC), which might result in an uncompressible microvascular bleeding disease. Despite tremendous advances in the understanding of the pathophysiology of TIC, a variety of unanswered questions persist and need to be addressed in future studies.

Many diagnostic and treatment strategies in severely coagulopathic trauma patients have been proposed so far, and massive transfusion protocols have been established in many hospitals to improve survival. However, there is still no broad consensus regarding the optimal strategies:

  • What is the optimal practical way to diagnose TIC?
  • How can we identify patients at risk for massive transfusion early?
  • Which is the best way to improve hemostatic competence to massively bleeding patients?
  • What are the optimal strategies in anticoagulated geriatric trauma patients?

In this Special Issue of the Journal of Clinical Medicine, we would like to offer researchers a platform to share recent scientific findings in the context of severely bleeding and coagulopathy trauma patients.

Dr. Herbert Schöchl
Prof. Dr. Oliver Grottke
Prof. Dr. Marc Maegele
Guest Editors

Manuscript Submission Information

Manuscripts should be submitted online at www.mdpi.com by registering and logging in to this website. Once you are registered, click here to go to the submission form. Manuscripts can be submitted until the deadline. All submissions that pass pre-check are peer-reviewed. Accepted papers will be published continuously in the journal (as soon as accepted) and will be listed together on the special issue website. Research articles, review articles as well as short communications are invited. For planned papers, a title and short abstract (about 100 words) can be sent to the Editorial Office for announcement on this website.

Submitted manuscripts should not have been published previously, nor be under consideration for publication elsewhere (except conference proceedings papers). All manuscripts are thoroughly refereed through a single-blind peer-review process. A guide for authors and other relevant information for submission of manuscripts is available on the Instructions for Authors page. Journal of Clinical Medicine is an international peer-reviewed open access semimonthly journal published by MDPI.

Please visit the Instructions for Authors page before submitting a manuscript. The Article Processing Charge (APC) for publication in this open access journal is 2600 CHF (Swiss Francs). Submitted papers should be well formatted and use good English. Authors may use MDPI's English editing service prior to publication or during author revisions.

Keywords

  • Trauma-induced coagulopathy
  • Diagnosis of TIC
  • Bleeding control in major trauma
  • Treatment strategies in severe bleeding trauma patients

Published Papers (5 papers)

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Research

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15 pages, 1570 KiB  
Article
Factor XIII Measurement and Substitution in Trauma Patients after Admission to an Intensive Care Unit
by Moritz Katzensteiner, Martin Ponschab, Herbert Schöchl, Daniel Oberladstätter, Johannes Zipperle, Marcin Osuchowski and Christoph J. Schlimp
J. Clin. Med. 2022, 11(14), 4174; https://doi.org/10.3390/jcm11144174 - 19 Jul 2022
Cited by 3 | Viewed by 1596
Abstract
Trauma patients admitted to an intensive care unit (ICU) may potentially experience a deficiency of coagulation factor thirteen (FXIII). In this retrospective cohort study conducted at a specialized trauma center, ICU patients were studied to determine the dependency of FXIII activity levels on [...] Read more.
Trauma patients admitted to an intensive care unit (ICU) may potentially experience a deficiency of coagulation factor thirteen (FXIII). In this retrospective cohort study conducted at a specialized trauma center, ICU patients were studied to determine the dependency of FXIII activity levels on clinical course and substitution with blood and coagulation products. A total of 189 patients with a median injury severity score (ISS) of 25 (16–36, IQR) were included. Abbreviated injury scores for extremities (r = −0.38, p < 0.0001) but not ISS (r = −0.03, p = 0.45) showed a negative correlation with initial FXIII levels. Patients receiving FXIII concentrate presented with a median initial FXIII level of 54 (48–59)% vs. 88 (74–108)%, p < 0.0001 versus controls; they had fewer ICU-free days: 17 (0–22) vs. 22 (16–24), p = 0.0001; and received higher amounts of red blood cell units: 5 (2–9) vs. 4 (1–7), p < 0.03 before, and 4 (2–7) vs. 1 (0–2), p < 0.0001 after FXIII substitution. Matched-pair analyses based on similar initial FXIII levels did not reveal better outcome endpoints in the FXIII-substituted group. The study showed that a low initial FXIII level correlated with the clinical course in this trauma cohort, but a substitution of FXIII did not improve endpoints within the range of the studied FXIII levels. Future prospective studies should investigate the utility of FXIII measurement and lower threshold values of FXIII, which trigger substitution in trauma patients. Full article
(This article belongs to the Special Issue Diagnosis, Treatment and Management of Trauma-Induced Coagulation Disorder: Current Updates and Perspectives)
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14 pages, 1858 KiB  
Article
A Multifunctional, Low-Volume Resuscitation Cocktail Improves Vital Organ Blood Flow and Hemostasis in a Pig Model of Polytrauma with Traumatic Brain Injury
by Alexander E. St. John, Xu Wang, Kristyn Ringgold, Esther B. Lim, Diana Chien, Matthew L. Statz, Susan A. Stern and Nathan J. White
J. Clin. Med. 2021, 10(23), 5484; https://doi.org/10.3390/jcm10235484 - 23 Nov 2021
Cited by 2 | Viewed by 1717
Abstract
The resuscitation of polytrauma with hemorrhagic shock and traumatic brain injury (TBI) is a balance between permissive hypotension and maintaining vital organ perfusion. There is no current optimal solution. This study tested whether a multifunctional resuscitation cocktail supporting hemostasis and perfusion could mitigate [...] Read more.
The resuscitation of polytrauma with hemorrhagic shock and traumatic brain injury (TBI) is a balance between permissive hypotension and maintaining vital organ perfusion. There is no current optimal solution. This study tested whether a multifunctional resuscitation cocktail supporting hemostasis and perfusion could mitigate blood loss while improving vital organ blood flow during prolonged limited resuscitation. Anesthetized Yorkshire swine were subjected to fluid percussion TBI, femur fracture, catheter hemorrhage, and aortic tear. Fluid resuscitation was started when lactate concentration reached 3–4 mmol/L. Animals were randomized to one of five groups. All groups received hydroxyethyl starch solution and vasopressin. Low- and high-dose fibrinogen (FBG) groups additionally received 100 and 200 mg/kg FBG, respectively. A third group received TXA and low-dose FBG. Two control groups received albumin, with one also including TXA. Animals were monitored for up to 6 h. Blood loss was decreased and vital organ blood flow was improved with low- and high-dose fibrinogen compared to albumin controls, but survival was not improved. There was no additional benefit of high- vs. low-dose FBG on blood loss or survival. TXA alone decreased blood loss but had no effect on survival, and combining TXA with FBG provided no additional benefit. Pooled analysis of all groups containing fibrinogen vs. albumin controls found improved survival, decreased blood loss, and improved vital organ blood flow with fibrinogen delivery. In conclusion, a low-volume resuscitation cocktail consisting of hydroxyethyl starch, vasopressin, and fibrinogen concentrate improved outcomes compare to controls during limited resuscitation of polytrauma. Full article
(This article belongs to the Special Issue Diagnosis, Treatment and Management of Trauma-Induced Coagulation Disorder: Current Updates and Perspectives)
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12 pages, 3822 KiB  
Article
Combined Administration of Fibrinogen and Factor XIII Concentrate Does Not Improve Dilutional Coagulopathy Superiorly Than Sole Fibrinogen Therapy: Results of an In-Vitro Thrombelastographic Study
by Emmanuel Schneck, Marcus Muelich, Melanie Markmann, Fabian Edinger, Nina Cooper, Annette Moeller, Gregor Bein, Andreas Hecker, Christian Koch, Michael Sander and Matthias Wolff
J. Clin. Med. 2021, 10(10), 2068; https://doi.org/10.3390/jcm10102068 - 12 May 2021
Cited by 3 | Viewed by 1840
Abstract
The early administration of fibrinogen has gained wide acceptance for the treatment of major hemorrhage, whereas the substitution of coagulation factor XIII (FXIII) is only supported by a low level of evidence. This study aimed to answer the question of whether a combined [...] Read more.
The early administration of fibrinogen has gained wide acceptance for the treatment of major hemorrhage, whereas the substitution of coagulation factor XIII (FXIII) is only supported by a low level of evidence. This study aimed to answer the question of whether a combined therapy of fibrinogen/FXIII substitution performs superiorly to sole fibrinogen administration in the treatment of dilutional coagulopathy. An in-vitro model of massive transfusion was used to compare the effect of combined fibrinogen/FXIII administration to that of sole fibrinogen therapy for the treatment of dilutional coagulopathy. For this purpose, the blood of red blood cell concentrates, fresh frozen plasma, and platelet concentrates were reconstituted in a ratio of 4:4:1, and then diluted with gelatin by 20% and 40%, respectively. Clot formation and stability were analyzed by thrombelastography. Both sole fibrinogen therapy (equivalent to 50 mg/kg) and the combined administration of fibrinogen (equivalent to 50 mg/kg) and FXIII (equivalent to 75 International Units (IU)/kg) increased fibrinogen-dependent mean clot firmness independently of the degree of dilution (20% dilution: 7 (6.3–7.8) mm; 20% dilution fibrinogen: 13.5 (13–17.3) mm; 20% dilution fibrinogen/FXIII: 16.5 (15.3–18.8) mm; 40% dilution: 3 (2–3.8) mm; 40% dilution fibrinogen: 8 (7–11.3) mm; 40% dilution fibrinogen/FXIII: 10 (8.3–11.8) mm; all p < 0.01). However, no differences were identified between the two treatment arms. Compared to fibrinogen therapy, no beneficial effect of the combined administration of fibrinogen and FXIII for the treatment of dilutional coagulopathy was detected in this in-vitro massive transfusion model. The result was independent of the degree of dilution. Full article
(This article belongs to the Special Issue Diagnosis, Treatment and Management of Trauma-Induced Coagulation Disorder: Current Updates and Perspectives)
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Review

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20 pages, 1972 KiB  
Review
Hemorrhagic Resuscitation Guided by Viscoelastography in Far-Forward Combat and Austere Civilian Environments: Goal-Directed Whole-Blood and Blood-Component Therapy Far from the Trauma Center
by James H. Lantry, Phillip Mason, Matthew G. Logsdon, Connor M. Bunch, Ethan E. Peck, Ernest E. Moore, Hunter B. Moore, Matthew D. Neal, Scott G. Thomas, Rashid Z. Khan, Laura Gillespie, Charles Florance, Josh Korzan, Fletcher R. Preuss, Dan Mason, Tarek Saleh, Mathew K. Marsee, Stefani Vande Lune, Qamarnisa Ayoub, Dietmar Fries and Mark M. Walshadd Show full author list remove Hide full author list
J. Clin. Med. 2022, 11(2), 356; https://doi.org/10.3390/jcm11020356 - 12 Jan 2022
Cited by 7 | Viewed by 2917
Abstract
Modern approaches to resuscitation seek to bring patient interventions as close as possible to the initial trauma. In recent decades, fresh or cold-stored whole blood has gained widespread support in multiple settings as the best first agent in resuscitation after massive blood loss. [...] Read more.
Modern approaches to resuscitation seek to bring patient interventions as close as possible to the initial trauma. In recent decades, fresh or cold-stored whole blood has gained widespread support in multiple settings as the best first agent in resuscitation after massive blood loss. However, whole blood is not a panacea, and while current guidelines promote continued resuscitation with fixed ratios of blood products, the debate about the optimal resuscitation strategy—especially in austere or challenging environments—is by no means settled. In this narrative review, we give a brief history of military resuscitation and how whole blood became the mainstay of initial resuscitation. We then outline the principles of viscoelastic hemostatic assays as well as their adoption for providing goal-directed blood-component therapy in trauma centers. After summarizing the nascent research on the strengths and limitations of viscoelastic platforms in challenging environmental conditions, we conclude with our vision of how these platforms can be deployed in far-forward combat and austere civilian environments to maximize survival. Full article
(This article belongs to the Special Issue Diagnosis, Treatment and Management of Trauma-Induced Coagulation Disorder: Current Updates and Perspectives)
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17 pages, 2063 KiB  
Review
Management of Coagulopathy in Bleeding Patients
by Stefan Hofer, Christoph J. Schlimp, Sebastian Casu and Elisavet Grouzi
J. Clin. Med. 2022, 11(1), 1; https://doi.org/10.3390/jcm11010001 - 21 Dec 2021
Cited by 11 | Viewed by 7257
Abstract
Early recognition of coagulopathy is necessary for its prompt correction and successful management. Novel approaches, such as point-of-care testing (POC) and administration of coagulation factor concentrates (CFCs), aim to tailor the haemostatic therapy to each patient and thus reduce the risks of over- [...] Read more.
Early recognition of coagulopathy is necessary for its prompt correction and successful management. Novel approaches, such as point-of-care testing (POC) and administration of coagulation factor concentrates (CFCs), aim to tailor the haemostatic therapy to each patient and thus reduce the risks of over- or under-transfusion. CFCs are an effective alternative to ratio-based transfusion therapies for the correction of different types of coagulopathies. In case of major bleeding or urgent surgery in patients treated with vitamin K antagonist anticoagulants, prothrombin complex concentrate (PCC) can effectively reverse the effects of the anticoagulant drug. Evidence for PCC effectiveness in the treatment of direct oral anticoagulants-associated bleeding is also increasing and PCC is recommended in guidelines as an alternative to specific reversal agents. In trauma-induced coagulopathy, fibrinogen concentrate is the preferred first-line treatment for hypofibrinogenaemia. Goal-directed coagulation management algorithms based on POC results provide guidance on how to adjust the treatment to the needs of the patient. When POC is not available, concentrate-based management can be guided by other parameters, such as blood gas analysis, thus providing an important alternative. Overall, tailored haemostatic therapies offer a more targeted approach to increase the concentration of coagulation factors in bleeding patients than traditional transfusion protocols. Full article
(This article belongs to the Special Issue Diagnosis, Treatment and Management of Trauma-Induced Coagulation Disorder: Current Updates and Perspectives)
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