/clinical/,/clinical/references/,/clinical/references/trauma-manual/,/clinical/references/trauma-manual/practice-guidelines/,/clinical/references/trauma-manual/practice-guidelines/management-of-coagulopathic-patient/,

/clinical/references/trauma-manual/practice-guidelines/management-of-coagulopathic-patient/

20170238

page

100

UWHC,UWMF,

https://uconnect.wisc.edu/media/u-connect/clinical-hub/references/trauma-manual/feature_trauma.jpg
Clinical Hub,References,Level I Adult Trauma Center Manual,Practice Guidelines

Management of Coagulopathic Patient

Management of Coagulopathic Patient - Clinical Hub, References, Level I Adult Trauma Center Manual, Practice Guidelines

Focus

Objective

Provide therapeutic guidance for management of trauma patients arriving with a pre-existing coagulopathy, arising from either therapeutic anticoagulation or disease.

Definitions

Anticoagulants: Typically heparin sulfate, low molecular weight heparins (i.e., Lovenox/ enoxaparin), warfarin agents (Coumadin), and anti-platelet agents (ASA, Ticlodipine, Dipyridamole)

Hereditary bleeding dyscrasias, lab abnormalities, and therapeutic goals:

FFP: Fresh Frozen Plasma, contains 200 units of all coagulation factors, complement, and 400 mg fibrinogen per unit, and is typically used in factor II, V, VIII, IX and XI deficient states. One unit of FFP raises the average level of these factors by 2%. Typical treatment dose starts with 2- 4 units; may need 10 -20 units to reverse serious coagulopathies (i.e., liver failure and Coumadin toxicity). Hypocalcemia with massive transfusion should be considered and treated.

Cryoprecipitate: Plasma concentrate consisting of factor VIII and fibrinogen. One unit contains 100 units of factor VIII and 250 mg fibrinogen. One unit equals 10 ml and will increase factor VIII activity by 2%. Typical dose is 8-10 units.

Platelets: One apheresis pack (usually containing 6-8 donor units) will increase platelet one hour count by 50,000. Counts should be repeated every 8-12 hours to address platelet consumption and need for repeat transfusion. Levels <20,000 are associated with spontaneous ICB’s and should be addressed regardless of injury. May be dosed as an apheresis pack or as a 6-8 random donor unit pack.

Vitamin K: Synthesized by intestinal flora; involved in hepatic production of factors II, VII, IX,
and X. Warfarin (Coumadin) is a vitamin K antagonist. Deficiency associated with increased
PTT, PT and normal bleeding time.

Guidelines

  1. General approach assumes blood loss will appear out of proportion to expected loss in patients with pre-existing coagulopathy
    1. Suspect underlying coagulopathy in any patient with unexplained blood loss. Review medications, family history and past medical history.
    2. If indicated, begin specific therapy for early anticoagulation reversal.
    3. Determine need for specific therapy using risk assessment table (see below).
  2. Risk Assessment (See Treatment Table)
    1. Assessing Bleed Risk:
      1. High Risk:
        1. CHI, spinal cord injury, spinal fracture (increased morbidity secondary to bleeding into a confined space).
        2. Spleen/liver/renal lacerations, grade 3,4, or 5
        3. Unstable pelvic fractures
      2. Moderate risk
        1. Multiple long bone fractures
        2. Stable pelvic fractures
        3. Hemothorax
        4. Splenic/liver/renal lacerations; grade 1 or 2
        5. Positive FAST or CT for pelvic fluid
      3. Low risk
        1. Extremity only injuries (monitor for compartment syndrome)
        2. Blunt chest or abdominal trauma without solid organ injury
    2. Assessing Risk of Anticoagulation Reversal
        1. High risk:
          1. Mechanical Heart valves
          2. Acute DVT (<1 month)
          3. Acute PE (<1 month)
        2. Moderate risk:
          1. Chronic DVT Rx (>1 month or <3 months)
          2. PE Rx(>1 month or <3 months)
          3. Hemophilia A
        3. Low Risk
          1. Chronic atrial fibrillation
          2. CVA/stroke Prophylaxis
          3. Chronic DVT/PE (>3 months)
          4. Von Willebrand’s disease
          5. Hemophilia B
          6. Other inherited coagulopathies
            Table
          7. If patient has mechanical heart valve consider starting heparin (PTT 45-55) 48 hours post injury and restarting Warfarin 7 days post injury
          8. Consider IVC filter if DVT/PE is reason for anticoagulation; discontinue anticoagulation until 7 days post injury
  3. Specific Therapy:
    1. Acute Reversal of patients receiving Warfarin:
      1. FFP: give 2 units and follow INR <1.5 (for patients with traumatic brain injury with positive CT findings consider starting with 4 units of FFP). If you have given 2 units and the bleeding appears to continue, give 2 more. Sometimes it takes 6-8 units of FFp to reverse the coagulopathy in an anticoagulated patient.
      2. Vitamin K (reversal time 6-24 hours) given to prevent “re-anticoagulation) 10mg subcutaneously qdx3 days, begin immediately. Use with caution based on risk.
    2. Patients receiving heparin:
      1. Rarely used in outpatient population. Hold infusion. Half-life is 90-120 minutes. Do NOT give protamine (doing so may lead to acute thrombosis).
      2. Patients Receiving LMWH – irreversible. Half life is approximately 12 hours. Patients require prolonged observation and supportive therapy.
    3. Hemophilia A:
      1. If bleed risk is high, give Factor VIII empirically to achieve therapeutic goal of >50% factor activity. If risk is moderate or low, check factor levels and dose accordingly. Monitor PTT and consult hematology.
      2. One unit/kg will raise Factor levels by 2%.
      3. In order to obtain 50% Factor activity (assuming low patient factor levels )begin with 40 units/kg every 12 hours (especially for CNS injury (see definition section) and obtain hematology consult. Therapeutic goal is >50% factor activity and 80% for CNS injury
    4. Von Willebrand’s Disease
      1. Bleed Risk is Moderate to Low unless patient has severe Disease
      2. Give cryo-precipitated vWF-enriched plasma; monitor PTT and bleed time; obtain hematology consult. Goal is >25% Factor Activity.
    5. Hemophilia B
      1. Bleed risk is Moderate to Low, therefore replace Factor IX using serum factor levels (goal is >50% factor activity; 80% for CNS) and clinical evaluation. One unit/kg of factor IX will increase Factor activity by 1%.
    6. Factor V Deficiency
      1. Treat with Factor V Replacement; usually via FFP transfusion (begin with 2 units).
      2. Obtain hematology consult
    7. Functional Platelet Defects and Th4rombocytopenia (platelet count <20,000)
      1. If bleed is significant give 6-8 units platelets, follow levels and bleed times; repeat every 6-8 hours as needed
      2. Reversing Hypothermia may correct platelet dysfunction
      3. DDAVP may be used as a nasal spray or as IV dose (0.3mg/kg, infused slowly).
  4. Specific Patients
    1. Traumatic Brain Injury
      1. CT negative, INR 1.5-3.0; admit for observation and hold Warfarin. Check INR in 6 hours and follow guideline
      2. CT negative, INR >3.0; admit and give FFP until INR 1.5-3.0; repeat CT in 12 hours
      3. CT with intracranial bleed, INR >1.5; admit to ICU and give FFP until INR <1.5; check fibrinogen level, as patient may require cryoprecipitate and is considered at risk for DIC. Repeat CT in 6 hours.
    2. Spinal Cord Injury -- INR >1.5; give PCC repeat INR in 1 hour and if >1.5 give additional dose of PCC or FFP and recheck INR until till <1.5 Give 2mg Vit. K IV.
    3. Chronic Liver Failure
      1. Patients will be deficient in Factors II, VII, IX and X. May require BOTH cryoprecipitate and FFP.
      2. Patients may be refractory to vitamin K secondary to hepatocyte dysfunction.
    4. Severe Bleed (INR>3) or Patient Receiving LMWH Therapy (See UWHC anticoagulation guideline)
      1. Give PCC repeat INR in 1 hour and if >1.5 give additional dose of PCC or FFP and recheck INR until <1,5 and give 2mg of Vitamin K IV.