Transfusion
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Shock and severe tissue injury lead to an endogenous coagulopathy mediated by activation of Protein C and hyperfibrinolysis known as acute traumatic coagulopathy. Together, hemodilution, acidosis, inflammation, and hypothermia result in a global trauma-induced coagulopathy. Coagulopathy in trauma is associated with mortality. Early and effective hemostatic resuscitation is critical in restoring perfusion, correcting coagulopathy, and saving lives in exsanguinating trauma. Lyophilized plasma (LP) provides a logistically superior alternative to fresh frozen plasma (FFP). ⋯ By minimizing the volume of reconstituted LP and optimizing its anti-inflammatory properties, an LP resuscitation fluid may be created to provide effective hemostatic resuscitation with superior logistical properties.
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This article examines how established and innovative techniques in hemorrhage control can be practically applied in a civilian physician-based prehospital trauma service. A "care bundle" of measures to control hemorrhage on scene are described. ⋯ More complex interventions include prehospital activation of massive hemorrhage protocols and administration of on-scene tranexamic acid, prothrombin complex concentrate, and red blood cells. Radical resuscitation interventions, such as prehospital thoracotomy for cardiac tamponade, and the potential future role of other interventions are also considered.
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Damage control resuscitation (DCR) is emerging as a standard practice in civilian and military trauma care. Primary objectives include resolution of immediate life threats followed by optimization of physiological status in the perioperative period. To accomplish this, DCR employs a unique hypotensive-hemostatic resuscitation strategy that avoids traditional crystalloid intravenous fluids in favor of early blood component use in ratios mimicking whole blood. ⋯ After reflecting on experiences from past conflicts, defining current capability gaps, and examining available and potential solutions, a strategy for "remote damage control resuscitation" (RDCR) has been proposed. In order for RDCR to progress from concept to clinical strategy, it will be necessary to define existing gaps in knowledge and clinical capability; develop a lexicon so that investigators and operators may understand each other; establish coherent research and development agendas; and execute comprehensive investigations designed to predict, diagnose, and mitigate the consequences of hemorrhagic shock and acute traumatic coagulopathy before they become irreversible. This article seeks to introduce the concept of RDCR; to reinforce the importance of identifying and optimally managing UMH and the resulting shock state as part of a comprehensive approach to out-of-hospital stabilization and en route care; and to propose investigational strategies to enable the development and broad implementation of RDCR principles.
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With the advent of remote damage control resuscitation and far-forward surgery, a renewed emphasis has been placed on examining a variety of pharmacologic adjuncts to controlling blood loss before definitive operative intervention. In this paper, the authors review the current state of the art for tranexamic acid (TXA) and its potential benefits to those patients who are in need of a massive transfusion. Specifically addressed are its biologic and pharmacologic properties, as well the results of a number of recent studies. ⋯ The 2012 Military Application of Tranexamic Acid in Trauma Emergency Resuscitation study provided a retrospective analysis of 896 wounded cared for at a military hospital in Afghanistan. This study demonstrated a 23.9%-17.4% reduction in all-cause mortality. Finally, they discuss the potential complications associated with TXA use as well as areas of future research, which are needed to solidify our knowledge of TXA and its potential beneficial effects on controlling bleeding.
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Coagulopathy after traumatic brain injury (TBI) is frequent and represents a powerful predictor related to outcome and prognosis. The complex pathophysiological mechanisms of the coagulopathy of TBI are multifactorial and remain still undefined. The nature of the coagulation abnormalities differs between severe TBI and non-TBI with somatic injuries. ⋯ Hemocoagulative disorders after TBI may be amenable to treatment, and adequate and timely management may protect from secondary injury and poor outcomes. Functional assays such as viscoelastic tests may be supportive in early detection, diagnosis, and guidance of treatment. This review summarizes the current understanding with regard to frequency, pathogenesis, diagnosis, and treatment of the coagulopathy after TBI.