How should patients who have suffered severe trauma and who then have acute hemorrhagic shock be treated prior to the initiation of hemostatic therapy? Dr. Herbert Schöchl, Department of Anaesthesiology and Intensive Care, AUVA Trauma Hospital, Salzburg, Austria, and the Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, Donaueschingenstrasse, Vienna, Austria, and Dr. Christoph J. Schlimpf, Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, Donaueschingenstrasse, Vienna, Austria, compared two approaches to control the treatment of trauma-induced coagulopathy (TIC). Their findings are published in this month’s edition of Anesthesia & Analgesia in the article titled “Trauma Bleeding Management: The Concept of Goal-Directed Primary Care.”
In the United States, the concept of ‘damage control resuscitation’ emphasizes the early and empiric administration of ratios of red blood cells (RBCs), fresh frozen plasma (FFP), and platelet concentrate (PC). In Europe, widespread use of early point-of-care (POC) viscoelastic testing is used as the basis for factor-specific resuscitation using product concentrates rather than plasma. No head-to-head comparison of these two approaches has been conducted (nor is it likely to be), but the authors make the point that they actually have much in common when compared to traditional approaches. Both ratio-driven and laboratory-driven approaches emphasize early support of the coagulation system, administration of an antifibrinolytic adjuvant (typically tranexamic acid), and aggressive administration of blood products rather than non-sanguineous fluids. Both approaches have been associated with improved outcomes when compared to historical data.
This manuscript provides an excellent review of the current concept of trauma-induced coagulopathy and provides practical insight into both diagnosis and treatment. Readers not yet familiar with the use of viscoelastic testing (thromboelastography [TEG®] or rotational thrombelastometry [ROTEM®]) or with current recommendations for massive transfusion will be well informed by this article. The case for early replacement of fibrinogen and for the use of antifibrinolytics is well presented, as is a sample management algorithm. The authors conclude by noting that the approaches outlined are actually converging on a common protocol that emphasizes rapid transfusion therapy with an early empiric approach but rapid transition to more specific therapy guided by point-of-care testing later.