References

Aitken LM, Hendrikz JK, Dulhunty JM, Rudd MJ Hypothermia and associated outcomes in seriously injured trauma patients in a predominantly sub-tropical climate. Resuscitation. 2009; 80:(2)217-23 https://doi.org/10.1016/j.resuscitation.2008.10.021

UK Ambulance Services clinical practice guidelines.Bridgwater, Somerset: Class Professional Publishing; 2016

Brohi K, Cohen MJ, Ganter MT Acute coagulopathy of trauma: hypoperfusion induces systemic anticoagulation and hyperfibrinolysis. J Trauma. 2008; 64:(5)1211-7 https://doi.org/10.1097/TA.0b013e318169cd3c

Brown JB, Cohen MJ, Minei JP Goal-directed resuscitation in the prehospital setting: a propensity-adjusted analysis. Trauma Acute Care Surg. 2013; 74:(5)1207-12 https://doi.org/10.1097/TA.0b013e31828c44fd

Campbell J Campbell's physiology notes for nurses.Hoboken, NJ: John Wiley & Sons, Ltd; 2006

Cole E, Davenport R, Willett K, Brohi K Tranexamic acid use in severely injured civilian patients and the effects on outcomes: a prospective cohort study. Ann Surg. 2015; 261:(2)390-4 https://doi.org/10.1097/SLA.0000000000000717

Credland N Managing the trauma patient presenting with the lethal triad. Int J Orthop Trauma Nurs. 2016; 20:45-53 https://doi.org/10.1016/j.ijotn.2015.09.003

Darlington DN, Kheirabadi BS, Delgado AV, Scherer MR, Martini WZ, Dubick MA Coagulation changes to systemic acidosis and bicarbonate correction in swine. J Trauma. 2011; 71:(5)1271-7 https://doi.org/10.1097/TA.0b013e318214f522

Davenport R Pathogenesis of acute traumatic coagulopathy. Transfusion. 2013; 53:23S-27S https://doi.org/10.1111/trf.12032

Dick F, Erdoes G, Opfermann P, Eberle B, Schmidli J, von Allmen RS Delayed volume resuscitation during initial management of ruptured abdominal aortic aneurysm. J Vasc Surg. 2013; 57:(4)943-50 https://doi.org/10.1016/j.jvs.2012.09.072

Dirkmann D, Hanke AA, Görlinger K, Peters J Hypothermia and acidosis synergistically impair coagulation in human whole blood. Anesth Analg. 2008; 106:(6)1627-32 https://doi.org/10.1213/ane.0b013e31817340ad

Duan K, Yu W, Li N The pathophysiology and management of acute traumatic coagulopathy. Clin Appl Thromb Hemost. 2015; 21:(7)645-52 https://doi.org/10.1177/1076029613516190

Eberhard LW, Morabito DJ, Matthay MA Initial severity of metabolic acidosis predicts the development of acute lung injury in severely traumatized patients. Crit Care Med. 2000; 28:(1)125-31 https://doi.org/10.1097/00043860-200004000-00018

Edwards S Cellular pathophysiology. Part 2 responses following hypoxia. Prof Nurs. 2003; 18:(11)636-639

Edwards SL Pathophysiology of acid base balance: the theory practice relationship. Intensive Crit Care Nurs. 2008; 24:(1)28-38 https://doi.org/10.1016/j.iccn.2007.05.003

Edwards S, Smith J Advances in military resuscitation. Emerg Nurse. 2016; 24:(6)25-9 https://doi.org/10.7748/en.2016.e1630

Floccard B, Rugeri L, Faure A Early coagulopathy in trauma patients: an on-scene and hospital admission study. Injury. 2012; 43:(1)26-32 https://doi.org/10.1016/j.injury.2010.11.003

Frith D, Brohi K The acute coagulopathy of trauma shock: clinical relevance. Surgeon. 2010; 8:(3)159-63 https://doi.org/10.1016/j.surge.2009.10.022

Gando S, Nanzaki S, Kemmotsu O Disseminated intravascular coagulation and sustained systemic inflammatory response syndrome predict organ dysfunctions after trauma: application of clinical decision analysis. Ann Surg. 1999; 229:(1)121-7 https://doi.org/10.1097/00000658-199901000-00016

Guyton A, Hall J Guyton and Hall textbook of medical physiology, 13th edn. Philadelphia, PA: Elsevier; 2015

Haut ER, Kalish BT, Cotton BA Prehospital intravenous fluid administration is associated with higher mortality in trauma patients: a National Trauma Data Bank analysis. Ann Surg. 2011; 253:(2)371-7 https://doi.org/10.1097/SLA.0b013e318207c24f

Hess JR, Holcomb JB, Hoyt DB Damage control resuscitation: the need for specific blood products to treat the coagulopathy of trauma. Transfusion. 2006; 46:(5)685-6 https://doi.org/10.1111/j.1537-2995.2006.00816.x

Holcomb JB, Fox EE, Wade CE The PRospective Observational Multicenter Major Trauma Transfusion (PROMMTT) study. J Trauma Acute Care Surg. 2013; 75:S1-2 https://doi.org/10.1097/TA.0b013e3182983876

Hussmann B, Lefering R, Waydhas C Does increased prehospital replacement volume lead to a poor clinical course and an increased mortality? A matched-pair analysis of 1896 patients of the Trauma Registry of the German Society for Trauma Surgery who were managed by an emergency doctor at the accident site. Injury. 2013; 44:(5)611-7 https://doi.org/10.1016/j.injury.2012.02.004

Ireland S, Endacott R, Cameron P, Fitzgerald M, Paul E The incidence and significance of accidental hypothermia in major trauma—a prospective observational study. Resuscitation. 2011; 82:(3)300-6 https://doi.org/10.1016/j.resuscitation.2010.10.016

Kermode JC, Zheng Q, Milner EP Marked temperature dependence of the platelet calcium signal induced by human von Willebrand factor. Blood. 1999; 94:(1)199-207

Kheirbek T, Kochanek AR, Alam HB Hypothermia in bleeding trauma: a friend or a foe?. Scand J Trauma Resusc Emerg Med. 2009; 17 https://doi.org/10.1186/1757-7241-17-65

Li B, Sun H Research progress of acute coagulopathy of trauma-shock. Chin J Traumatol. 2015; 18:(2)95-7

Lippi G, Bonfanti L, Saccenti C, Cervellin G Causes of elevated D-dimer in patients admitted to a large urban emergency department. Eur J Intern Med. 2014; 25:(1)45-8 https://doi.org/10.1016/j.ejim.2013.07.012

Lundgren P, Henriksson O, Naredi P, Björnstig U The effect of active warming in prehospital trauma care during road and air ambulance transportation—a clinical randomized trial. Scand J Trauma Resusc Emerg Med. 2011; 19 https://doi.org/10.1186/1757-7241-19-59

MacDonald RD Articles that may change your practice: crystalloid and blood products. Air Med J. 2015; 34:(1)19-22 https://doi.org/10.1016/j.amj.2014.10.006

Maegele M, Lefering R, Yucel N Early coagulopathy in multiple injury: an analysis from the German Trauma Registry on 8724 patients. Injury. 2007; 38:(3)298-304 https://doi.org/10.1016/j.injury.2006.10.003

Marieb E, Hoehn K Human Anatomy & physiology, 9th edn. Glenview, IL: Pearson Education; 2012

Martini WZ Coagulopathy by hypothermia and acidosis: mechanisms of thrombin generation and fibrinogen availability. J Trauma. 2009; 67:(1)202-8 https://doi.org/10.1097/TA.0b013e3181a602a7

Martini WZ Coagulation complications following trauma. Mil Med Res. 2016; 3:(1) https://doi.org/10.1186/s40779-016-0105-2

Martini WZ, Dubick MA, Pusateri AE, Park MS, Ryan KL, Holcomb JB Does bicarbonate correct coagulation function impaired by acidosis in swine?. J Trauma. 2006; 61:(1)99-106 https://doi.org/10.1097/01.ta.0000215574.99093.22

Meng ZH, Wolberg AS, Monroe DM, Hoffman M The effect of temperature and pH on the activity of factor VIIa: implications for the efficacy of high-dose factor VIIa in hypothermic and acidotic patients. J Trauma. 2003; 55:(5)886-91 https://doi.org/10.1097/01.TA.0000066184.20808.A5

Michiels C Physiological and pathological responses to hypoxia. Am J Pathol. 2004; 164:(6)1875-82 https://doi.org/10.1016/S0002-9440(10)63747-9

Mitrophanov AY, Rosendaal FR, Reifman J Computational analysis of the effects of reduced temperature on thrombin generation: the contributions of hypothermia to coagulopathy. Anesth Analg. 2013; 117:(3)565-74 https://doi.org/10.1213/ANE.0b013e31829c3b22

Moffatt SE Hypothermia in trauma. Emerg Med J. 2013; 30:(12)989-96 https://doi.org/10.1136/emermed-2012-201883

Morrison CA, Carrick MM, Norman MA Hypotensive resuscitation strategy reduces transfusion requirements and severe postoperative coagulopathy in trauma patients with hemorrhagic shock: preliminary results of a randomized controlled trial. J Trauma. 2011; 70:(3)652-63 https://doi.org/10.1097/TA.0b013e31820e77ea

Morrison JJ, Dubose JJ, Rasmussen TE, Midwinter MJ Military Application of Tranexamic Acid in Trauma Emergency Resuscitation (MATTERs) study. Arch Surg. 2012; 147:(2)113-9 https://doi.org/10.1001/archsurg.2011.287

National Institute for Health and Care Excellence. Blood transfusion. 2015. http//www.nice.org.uk/ng24 (accessed 23 November 2018)

National Institute for Health and Care Excellence. Major trauma: assessment and initial management. 2017. http//www.nice.org.uk/ng39 (accessed 23 November 2018)

Nolan J Advanced life support, 7th edn. London: Resuscitation Council UK; 2015

Pearson J, Round J, Ingram M Management of shock in trauma. Anaesth Intensive Care Med. 2014; 15:(9)408-10 https://doi.org/10.1016/j.mpaic.2014.06.007

Raza I, Davenport R, Rourke C The incidence and magnitude of fibrinolytic activation in trauma patients. J Thromb Haemost. 2013; 11:(2)307-14 https://doi.org/10.1111/jth.12078

Reade MC, Pitt V, Gruen RL Tranexamic acid and trauma: current status and knowledge gaps with recommended research priorities. Shock. 2013; 40:(2)160-1 https://doi.org/10.1097/SHK.0b013e31829ab240

Roberts I, Shakur H, Coats T The CRASH-2 trial: a randomised controlled trial and economic evaluation of the effects of tranexamic acid on death, vascular occlusive events and transfusion requirement in bleeding trauma patients. Health Technol Assess. 2013; 17:(10)1-79 https://doi.org/10.3310/hta17100

Rossaint R, Bouillon B, Cerny V The European guideline on management of major bleeding and coagulopathy following trauma: fourth edition. Crit Care. 2016; 20 https://doi.org/10.1186/s13054-016-1265-x

Shere-Wolfe RF, Galvagno SM, Grissom TE Critical care considerations in the management of the trauma patient following initial resuscitation. Scand J Trauma Resusc Emerg Med. 2012; 20 https://doi.org/10.1186/1757-7241-20-68

Simmons JW, Pittet JF, Pierce B Trauma-induced coagulopathy. Curr Anesthesiol Rep. 2014; 4:(3)189-99 https://doi.org/10.1007/s40140-014-0063-8

Simmons JW, Powell MF Acute traumatic coagulopathy: pathophysiology and resuscitation. Br J Anaesth. 2016; 117:iii31-iii43

Skellett S, Mayer A, Durward A, Tibby SM, Murdoch IA Chasing the base deficit: hyperchloraemic acidosis following 0.9% saline fluid resuscitation. Arch Dis Child. 2000; 83:(6)514-6 https://doi.org/10.1136/adc.83.6.514

Søreide K Clinical and translational aspects of hypothermia in major trauma patients: from pathophysiology to prevention, prognosis and potential preservation. Injury. 2014; 45:(4)647-54 https://doi.org/10.1016/j.injury.2012.12.027

Sorensen B, Fries D Emerging treatment strategies for trauma-induced coagulopathy. Br J Surg. 2012; 99:40-50 https://doi.org/10.1002/bjs.7770

Theusinger OM, Baulig W, Levy JH Coagulation in trauma. Trends Anaesth Crit Care. 2015; 5:(1)23-7 https://doi.org/10.1016/j.tacc.2014.10.006

Thorsen K, Ringdal KG, Strand K, Søreide E, Hagemo J, Søreide K Clinical and cellular effects of hypothermia, acidosis and coagulopathy in major injury. Br J Surg. 2011; 98:(7)894-907 https://doi.org/10.1002/bjs.7497

White NJ Mechanisms of trauma-induced coagulopathy. Hematology Am Soc Hematol Educ Program. 2013; 2013:660-3 https://doi.org/10.1182/asheducation-2013.1.660

Injuries and violence: the facts.Geneva: WHO; 2010

trauma

prehospital

management

injury

clinical skills

Acute traumatic coagulopathy: the lethal triad of trauma

02 December 2018

Features

02 December 2018

Volume 10 · Issue 12

ISSN (print): 1759-1376

ISSN (online): 2041-9457

Abstract

Trauma is the leading cause of death for people in the UK and North America, especially for those aged 15–24 years. However, if early management regimes of permissive hypotension, high-flow oxygen and administration of tranexamic acid are applied, mortality risk can be reduced significantly. Acute traumatic coagulopathy (ATC) is an internal process that is initiated by significant or massive trauma because of hypoperfusion resulting in hypovolaemic shock, activation of protein C, platelet dysfunction and disruption to the endothelial glycocalyx. ATC can be exacerbated by hypothermia, acidosis and dilution coagulopathy—the ‘lethal triad’ of trauma. This article discusses the pathophysiology of ATC and treatment strategies via the management of the lethal triad.

Trauma is a primary contributor to the burden of disease globally (World Health Organization (WHO), 2010). In the UK and North America, trauma is the leading cause of death for people aged 1–44 years, with 70% of these deaths occurring to those in the 15–24 age group (WHO, 2010). Trauma haemorrhage is the leading cause of preventable deaths, accounting for approximately 40% of all cases worldwide (Frith and Brohi, 2010).

Acute traumatic coagulopathy (ATC) is an internal process initiated by significant trauma because of hypoperfusion resulting from hypovolaemic shock, activation of protein C, platelet dysfunction and disruption to the endothelial glycocalyx (Duan et al, 2015). ATC can be exacerbated by hypothermia, acidosis and dilution coagulopathy, which together are known as the ‘lethal triad’ of trauma (Credland, 2016).

Subscribe to get full access to the Journal of Paramedic Practice

Thank you for visiting the Journal of Paramedic Practice and reading our archive of expert clinical content. If you would like to read more from the only journal dedicated to those working in emergency care, you can start your subscription today for just £48.

What's included

CPD Focus
Develop your career
Stay informed

Or continue by

Signing in with your registered email address

Trauma

Lethal triad

Acute traumatic coagulopathy

Hypothermia

Acidosis