Trauma Guideline Manual - SUNY Upstate Medical University

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126____________ Trauma Guidelines ManualSUNY Upstate Trauma Centerc. If patient has mechanical heart valve consider starting heparin (PTT 45 -55) 48hours post-injury and restarting Coumadin 7 days post-injury.d. Consider vena cava filter if DVT/PE is reason for anticoagulation; discontinueanticoagulation until 7 days post-injury.3. Specific Therapy( Link to UUH anticoagulation guideline)a. Acute Reversal of Patients Receiving Coumadini. FFP: give 2 units and follow INR; target INR 50% factor activity. If risk is Moderate or Low, check Factorlevels and dose accordingly. Monitor PTT and consult hematology.ii. One unit/kg will raise Factor levels by 2%.iii. In order to obtain 50% Factor activity (assuming low patient factor levels)begin with 40 units/kg every 12 hours (especially for CNS injury, seeDefinition section) and obtain hematology consult. Therapeutic goal is>50% factor activity and 80% for CNS injury.d. Von Willebrand’s Diseasei. Bleed risk is Moderate to Low unless patient has severe von Willebrand’sDisease.ii. Give cryo-precipitated vWF–enriched plasma; monitor PTT and bleedtime; obtain hematology consult. Goal is >25% Factor activity.e. Hemophilia Bi. Bleed risk is Moderate to Low, therefore replace Factor IX using serumfactor levels (goal is >50% factor activity; 80% for CNS) and clinicalevaluation. One unit/kg of factor IX will increase Factor activity by 1%.ii. For serious bleeding, start with 60 units/kg BIDiii. Obtain hematology consult.f. Factor V Deficiencyi. Treat with Factor V Replacement, usually via FFP transfusion (begin with2 units).ii. Obtain hematology consult.g. Functional Platelet Defects and Thrombocytopenia (platelet count < 20,000)
Trauma Guideline Manual______________SUNY Upstate Trauma Center1274. Specific Patientsi. If bleed is significant give 1 pharesis pack of platelets, follow levels andbleed times; repeat every 6-8 hours as needed.ii. Reversing hypothermia may correct platelet dysfunction.iii. DDAVP (Stimate) may be used as nasal spray or as intravenous dose(0.3mg/kg, infused slowly).a. Traumatic Brain Injuryi. CT negative, INR 1.5-3.0; admit for observation and hold Coumadin.Check INR in 6 hours and follow guideline.ii. CT negative, INR >3.0; admit and give FFP until INR 1.5-3.0 (usually 4units); repeat CT in 12hoursiii. CT with intracranial bleed, INR >1.5; admit to ICU and give PCC repeatINR in 1 hour and if >1.5 give additional dose of PCC or FFP. Give 2mgVit. K IV. Repeat CT scan in 6 hours.b. Spinal Cord Injury -- INR >1.5; give PCC repeat INR in 1 hour and if >1.5 giveadditional dose of PCC or FFP and recheck INR till 1.5; patients will be deficient in Factors II, VII, IX and X. May requireBOTH cryoprecipitate and FFP.ii. Patients may be refractory to vitamin K secondary to hepatocytedysfunction.d. Severe Bleed (INR>3) or Patient Receiving LMWH Therapy(Link to UUH anticoagulation guideline)i. Give PCC repeat INR in 1 hour and if >1.5 give additional dose of PCC orFFP and recheck INR till
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Trauma Guideline Manual - SUNY Upstate Medical University

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