Coagulation management in major trauma

Bleeding is a common problem in major trauma. Coagulopathy could be detected in approximately 25% of all trauma patients on arrival in the emergency room. The reasons for that are blood loss, dilution of the remaining coagulation factors by fluids not containing coagulation factors, consumption of coagulation factors and hyperfibrinolysis. Hypothermia and acidosis are also well described contributors of coagulopathy. Diagnosis of coagulation abnormalities should be based on clinical judgement. Standard coagulation tests are universally available, but there is some evidence, that those tests are not predictive for transfusion requirement. Thrombelastography/metry is a promising technology which not only shows the initiation of the coagulation process but also the dynamic of clot formation and the clot firmness. It is the golden standard for the diagnosis of hyperfibrinolysis. To restore adequate haemostasis an aggressive treatment of hypothermia and acidosis is essential. The concept of damage control surgery and permissive hypotension in server bleeding patients could reduce the whole amount of blood loss. For coagulation factor replacement therapy fresh frozen plasma, PCC, fibrinogen concentrates and cryoprecipitate could be used. Haematocrit should be maintained in the range of 30% and platelet count should not drop below 50 000/μl. In some circumstances haemostatic agents such as DDAVP, antifibrinolytics and rFVIIa could be helpful, even there is no conclusive evidence for the use of these drugs in severe trauma patients.