Current challenges and future clinical management of bleeding and coagulopathy after trauma

摘要

Injury is the principal cause of death among people 44 years of age or younger. Bleeding coupled with coagulopathy remains the leading cause of early in-hospital mortality in trauma. Trauma coagulopathy can be defined as endogenous and iatrogenic. Endogenous trauma coagulopathy develops early following traumatic injury; is mediated by increased activated protein C activity, inhibition of thrombin generation and fibrinolysis; and is associated with a 3-fold increase in death in trauma. Iatrogenic trauma coagulopathy is a late phenomenon, usually developing after aggressive crystalloid resuscitation, metabolic acidosis and hypothermia. Current management strategies for trauma resuscitation aim at not only replenishing volume to increase cardiac output and oxygen delivery to tissues, but also at preventing and/or correcting trauma coagulopathies. Two main resuscitation strategies are currently available: ratio-based transfusion protocols and laboratory-guided resuscitation protocols. Several engineered biomaterials are now available as delivery systems for systemic hemostatic adjuncts to transfusion. Tranexamic acid, fibnnogen concentrates, recombinant factor Ⅶa, prothrombin complex concentrates and freeze-dried plasma are used with some benefit in the management of coagulopathy in trauma. Furthermore, biomaterials for hemorrhage control such was solid biopolymers, ceramics and liquid tissue sealant-based local hemostatic agents are also available. Finally, massive transfusion protocols are organized approach to trauma resuscitation expediting delivery of care.