Trauma
concentrate first line, PCC and FXIII)
replacement in a cohort of major trauma
patients. Significantly fewer patients in
the coagulation factor concentrate group
received massive transfusion and fewer
patients received ‘rescue’ therapy by
changing the treatment groups. However,
the primary outcome, which was
multi-organ failure, was not different
between groups (the study was stopped at
50% recruitment). 8 One study compared
a ROTEM-guided coagulation therapy
based on coagulation factor concentrates
(fibrinogen concentrate and PCC) with
controls from the German Trauma
Registry, treated with FFP. RBC and PC
transfusions were avoided in significantly
higher proportions of patients in the
coagulation factor concentrate group.
However, no difference in mortality was
observed. 50
Conclusions
It remains unclear whether early
substitution of coagulation factor
concentrate can improve outcome in
major trauma-related bleeding. However,
it has been clearly established that
coagulation factor concentrates allow
rapid and targeted supplementation of
pro-coagulants, and that the
administration of fibrinogen concentrate
in cases of TIC effectively treats early and
critical fibrinogen depletion. Thus,
fibrinogen concentrate confers significant
advantages in both safety and speed of
administration over FFP transfusion for
supplementation of fibrinogen. In
addition, PCCs effectively increase the
content of vitamin K-dependent
coagulation factors and is clearly superior
compared with FFP transfusion.
26
References
1 Krug EG, Sharma GK, Lozano R. The global burden
of injuries. Am J Public Health 2000;90:523–6.
2 Sauaia A et al. Epidemiology of trauma deaths:
a reassessment. J Trauma 1995;38:185–93.
3 Brohi K et al. Acute traumatic coagulopathy.
J Trauma 2003;54:1127–30.
4 Holcomb JB et al; PROPPR Study Group. Transfusion
of plasma, platelets, and red blood cells in a 1:1:1 vs
a 1:1:2 ratio and mortality in patients with severe
trauma: the PROPPR randomized clinical trial. JAMA
2015;313(5):471–82.
5 Balvers K et al; Targeted Action for Curing
Trauma-Induced Coagulopathy (TACTIC)
Collaborators. Combined effect of therapeutic
strategies for bleeding injury on early survival,
transfusion needs and correction of coagulopathy.
Br J Surg 2017;104(3):222–9.
6 Schöchl H et al. Goal-directed coagulation
management of major trauma patients using
thromboelastometry (ROTEM)-guided administration
of fibrinogen concentrate and prothrombin complex
concentrate. Crit Care 2010;14(2):R55.
7 Stein P et al. Change of transfusion and
treatment paradigm in major trauma patients.
hospitalpharmacyeurope.com
Anaesthesia 2017;72(11):1317–26.
8 Innerhofer P et al. Reversal of trauma-induced
coagulopathy using first-line coagulation factor
concentrates or fresh frozen plasma (RETIC): a
single-centre, parallel-group, open-label, randomised
trial. Lancet Haematol 2017;4(6):e258–e271.
9 Nardi G et al. Trauma-induced coagulopathy:
impact of the early coagulation support protocol on
blood product consumption, mortality and costs. Crit
Care 2015;19:83.
10 Maegele M. Frequency, risk stratification and
therapeutic management of acute post-traumatic
coagulopathy. Vox Sang 2009;97(1):39–49.
11 Chambers LA, Chow SJ, Shaffer LE. Frequency and
characteristics of coagulopathy in trauma patients
treated with a low- or high-plasma-content massive
transfusion protocol. Am J Clin Pathol 2011;136(3):
364–70.
12 Hagemo JS et al. Prevalence, predictors and
outcome of hypofibrinogenaemia in trauma:
a multicentre observational study. Crit Care
2014;18(2):R52.
13 McQuilten ZK et al. Fibrinogen is an independent
predictor of mortality in major trauma patients:
A five-year statewide cohort study. Injury
2017;48(5):1074–81.
14 Schöchl H et al. FIBTEM provides early prediction
of massive transfusion in trauma. Crit Care
2011;15(6):R265.
15 Mosesson MW. Update on antithrombin I (fibrin).
Thromb Haemost 2007;98(1):105–8.
16 Floccard B et al. Early coagulopathy in trauma
patients: an on-scene and hospital admission study.
Injury 2012;43(1):26–32.
17 Schlimp CJ et al. Estimation of plasma fibrinogen
levels based on hemoglobin, base excess and Injury
Severity Score upon emergency room admission. Crit
Care 2013;17(4):R137.
18 Rossaint R et al. The European guideline on
management of major bleeding and coagulopathy
following trauma: fourth edition. Crit Care
2016;20:100.
19 Aubron C et al. Efficacy and safety of fibrinogen
concentrate in trauma patients – a systematic review.
J Crit Care 2014;29(3):471.e11–7.
20 Ponschab M et al. Haemostatic profile of
reconstituted blood in a proposed 1:1:1 ratio of packed
red blood cells, platelet concentrate and four different
plasma preparations. Anaesthesia 2015;70(5):
528–36.
21 Theusinger OM et al. Relative concentrations
of haemostatic factors and cytokines in solvent/
detergent-treated and fresh-frozen plasma.
Br J Anaesth 2011;106(4):505–11.
22 Rourke C et al. Fibrinogen levels during trauma
hemorrhage, response to replacement therapy, and
association with patient outcomes. J Thromb
Haemost 2012;10(7):1342–51.
23 Curry N et al. Early cryoprecipitate for major
haemorrhage in trauma: a randomised controlled
feasibility trial. Br J Anaesth 2015;115(1):76–83.
24 Sørensen B, Bevan D. A critical evaluation of
cryoprecipitate for replacement of fibrinogen.
Br J Haematol 2010;149(6):834–43.
25 Solomon C et al