Trauma Guideline Manual - SUNY Upstate Medical University

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124____________ Trauma Guidelines ManualSUNY Upstate Trauma CenterPRACTICE GUIDELINES: MANAGEMENT OF THE COAGULOPATHIC TRAUMA PATIENTOBJECTIVE:Provide therapeutic guidance for management of trauma patients arriving with a pre-existingcoagulopathy, 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:• Hemophilia A (Factor VIII), isolated elevated PTT; Factor VIII half-life is 12 hr,therapeutic goal is >50% Factor VIII activity; for CNS injury, therapeutic goal is >80%• Hemophilia B (factor IX), isolated elevated PTT; Factor IX half-life is 20-30 hr,therapeutic goal is >50% activity except for CNS injury, where therapeutic goal is >80%• Von Willebrand’s disease (vWF, factor VIII), elevated bleeding time and PTT; half-life is24 hr, therapeutic goal is >25% Factor activity• Other inherited Factor deficiencies (commonly Factor V)• Chronic liver failure (II, VII, IX, X), elevated INRFFP: Fresh Frozen Plasma, contains 200 units of all coagulation factors, complement, and 400mg fibrinogen per unit, and is typically used in factor II, V, VIII, IX and XI deficient states. Oneunit 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 andCoumadin toxicity). Hypocalcemia with massive transfusion should be considered and treated.Cryoprecipitate: Plasma concentrate consisting of factor VIII and fibrinogen. One unit contains100 units of factor VIII and 250 mg fibrinogen. One unit equals 10 ml and will increase factorVIII activity by 2%. Typical dose is 8-10 units.Platelets: One aphereis pack (usually containing 6-8 donor units) will increase platelet onehourcount by 50,000. Counts should be repeated every 8-12 hours to address plateletconsumption and need for repeat transfusion. Levels
Trauma Guideline Manual______________SUNY Upstate Trauma Center125a. Suspect underlying coagulopathy in any patient with unexplained blood loss.Review medications, family history and past medical history.b. If indicated, begin specific therapy for early anticoagulation reversal.c. Determine need for specific therapy using risk assessment table (see below).2. Risk Assessment (See Treatment Table)a. Assessing Bleed Riski. High Risk1. CHI, spinal cord injury, spinal fracture (increased morbiditysecondary to bleeding into a confined space)2. Splenic/liver/renal lacerations; Grade 3, 4, or 53. Unstable pelvic fracturesii. Moderate Risk1. Multiple long bone fractures2. Stable pelvic fractures3. Hemothorax4. Splenic/liver/renal lacerations; Grade 1 or 2iii.5. Positive FAST or CT for pelvic fluidLow Risk1. Extremity-only injuries (monitor for Compartment Syndrome)2. Blunt chest or abdominal trauma, without solid organ injuryb. Assessing Risk of Anticoagulation Reversali. High Risk1. Mechanical Heart Valves2. Acute DVT (< 1 month)3. Acute PE (< 1 month)ii.iii.Moderate Risk1. Chronic DVT Rx ( >1 month or < 3 months)2. PE Rx ( > 1 month or < 3 months)3. Hemophilia ALow Risk1. Chronic Atrial Fibrillation2. CVA/Stroke Prophylaxis3. Chronic DVT/PE (> 3 months)4. Von Willebrand’s disease5. Hemophilia B6. Other inherited coagulopathiesTreatment TableBleed RiskRisk ofHigh Moderate LowReversalReverse Hold 24 hrs ContinueHigh(a,b) (a,b) therapyReverse Hold 48 hrsModerateHold(b) (b)Low Reverse Reverse Hold
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Trauma Guideline Manual - SUNY Upstate Medical University

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