Trauma
in depletion of coagulation proteins
but also in a critical drop in platelets. 28
Data from animal studies revealed
that high fibrinogen levels might
potentially counteract low platelet
counts, by increasing overall clot
firmness. 29 Velik-Salcher et al
investigated the effect of fibrinogen
concentrate transfusion on blood loss in
a thrombocytopenic swine model (target
platelet count < 30,000/µl). Transfusion
of fibrinogen concentrate (250mg/kg
body weight) resulted in lower blood loss
and improved survival rate compared
with transfusion of 2U of PC. 29 In
situations where platelet count is low or
platelet function is compromised and PCs
are not available, high fibrinogen
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supplementation might be considered
as a treatment option. 30
Fibrinogen supplementation
Nascimento et al randomised 50
hypotensive adult trauma patients to
either 6g fibrinogen concentrate or
placebo. Plasma fibrinogen
concentrations remained higher in the
fibrinogen concentrate group up to 12h
after admission. Mortality and
thromboembolic complications were
similar between groups. 31
Thrombin generation is initially not
deficient in major trauma
Compromised thrombin generation does
not appear an initial problem in the early
stages of TIC. 32,33 Therefore thrombin-
generating coagulation factors such as
prothrombin complex concentrate (PCC)
are not advocated as first-line therapy in
trauma. 34 Importantly, prolonged
standard coagulation tests such as
international normalised ratio (INR),
prothrombin time (PT), activated partial
thromboplastin time, ROTEM clotting
time or TEG r- and k-time do not
sufficiently reflect impaired thrombin
production. For example, Dunbar and
Chandler reported 15 trauma patients
with prolonged PT and INR suggestive of
TIC. Even though PT was >18 sec and
INR was >1.5, thrombin generation was
three-fold higher compared with controls
(p=0.01). 32