Coagulation Factors in Controlling Traumatic Bleeds: FFP, PCC, or ...

i. Patients with none of these risk factors had 1% chance of developing life-threatening
coagulopathy 11
ii. Patients with coagulopathy on admission had significantly higher mortality rates than those with
normal clotting on admission (46% vs. 10.9%) 12
iii. Abnormal admission PT increases adjusted odds of dying by 35%; abnormal aPTT increases
adjusted odds of dying by 326% 13
1. PT: evaluates adequacy of the extrinsic pathway; clotting ability of factors I, II, V, VII, X 14
2. PTT: measures efficacy of both the intrinsic and common coagulation pathways; evaluates
factors I, II, V, VIII, IX, X, XI, and XII 14
WAR FAR IN
VI. Warfarin + Trauma = Bad 4,17
a. Increasing need to manage trauma patients who receive anticoagulation
i. Expanding warfarin use due to expanding aging population
1. Use increased from 2.3% to 4.0% from 2002 to 2006
2. Use in patients > 65 years increased from 7.3% to 12.8% from 2002 to 2006
3. 1-10% annual incidence of major bleeding in warfarin patients
ii. Increasing trauma rates in patients ≥ 65 years
1. 2009: 20.8% trauma cases in patients ≥ 65 years – increased from 15.3% in 2004
b. Traumatically injured patients receiving warfarin at higher risk for severe intracranial hemorrhage and
uncontrolled bleeding
i. Four- to five-fold increased risk of death in anticoagulated trauma patients vs. non-anticoagulated
trauma patients 18
ii. Increased anticoagulation intensity increases risk of hemorrhagic events 19
1. 98,900 patient years of observation
2. Evaluated how under- and over-anticoagulation influence patient outcomes
3. Compared with INR 2.0-3.0, relative risk of hemorrhagic events was 2.7 (absolute risk
3.7%/year) at INR 3.0-5.0, and 21.8 (absolute risk 30.1%/year) for INR >5.0
iii. Rapid reversal of anticoagulation in trauma patients necessary to prevent or minimize
hemorrhagic complications
1. Protocol of rapid identification of intracranial bleeding and warfarin reversal decreased
intracranial hemorrhage progression and reduced mortality 20
VII. Pharmacology 15
a. Vitamin K antagonist (VKA)
b. Commonly prescribed for treatment and prevention of thromboembolic events
c. Inhibits enzyme, vitamin K epoxide reductase (VKORC1)
blocks formation of reduced vitamin K from vitamin K epoxide
i. Reduced form of vitamin K required for biological activity of extrinsic coagulation factors
d. Response to warfarin influenced by several factors (medications, diet, pharmacogenomics, etc.)
e. PT used in clinical practice as a therapeutic response marker
i. INR used to standardize its reporting [INR = (patient PT/mean PT) ISI ]
ii. Moderate intensity anticoagulation (INR 2.0-3.0) recommended for most indications
iii. Safety and efficacy depend on maintaining INR within therapeutic range
VIII. Questions to answer
a. What treatment strategies should be used in traumatic bleeding patients on warfarin pre-injury?
b. What treatment strategies should be used in traumatic bleeding patients NOT on warfarin pre-injury?
R. Sohraby 5