More than 30 percent of people presenting to emergency departments have acute coagulopathy. Unfortunately, some of these patients may be overlooked — either because they don't seem at risk of coagulation problems or because the trauma bay is overwhelmed with serious injuries.
Terri A. Elsbernd, R.N., pediatric trauma coordinator at Mayo Clinic in Rochester, Minn., says that although it can prove challenging for emergency nurses, early identification of coagulopathy in patients with multisystem injuries is crucial. "Patients who have coagulopathy are four times more likely to die than those who don't," she says. "An understanding of the pathophysiology involved as well as rapid recognition and intervention can decrease mortality."
Coagulopathy can be reversed with vitamin K or fresh frozen plasma, but the window of opportunity is small and occurs soon after injury. "It's important to obtain prothrombin and PTT times as soon as possible — before there is increased bleeding in the brain or ongoing hemorrhage," Elsbern says. She adds that Mayo helicopters carry frozen plasma for patients needing transfer.
Elsbernd explains that the understanding of coagulation dysfunction in severely injured patients has evolved considerably in the past decade. The idea that trauma-induced coagulopathy occurs because fluids dilute clotting factors is no longer accepted, she says, and the concept of intrinsic and extrinsic pathways has largely been disproved. Instead, it is now thought that acute coagulopathy correlates with activation of the protein C pathway and is exacerbated by hypothermia.
"Clotting mechanisms are temperature-dependent," Elsbernd explains, "and almost everything that happens to trauma patients makes them cold. Some hypothermia is exposure-related, but it often develops in transport or in the hospital where patients are lightly clothed and given cold IV fluids. In an effort to reduce hypothermia, we now heat our trauma bay to 78 F."
Warfarin and other anticoagulants also significantly increase the risk of coagulopathy, but that risk may be less apparent in people with minor injuries.
"Some of the highest mortality in the Mayo Clinic Trauma Center involves older adults who have same-level falls and are anticoagulated," Elsbernd says. "Often, they don't come to the hospital right away and by the time they do, it's too late to reverse the bleeding. That's why we urge other hospitals to check for coagulopathy, even in cases of limited trauma. In our experience, minor injuries result in the some of the highest morbidity and mortality."
Elsbernd stresses that in all cases, it's important to identify people with traumatic coagulopathy early. "If the problem can't be corrected in a timely manner, then those patients should be transferred to a center that provides definitive care," she says.