Trauma-Induced Coagulopathy: An Institution's 35 Year Perspective on Practice and Research.
BACKGROUND
Injury is the second leading cause of death worldwide, and as much as 40% of injury-related mortality is attributed to uncontrollable hemorrhage. This persists despite establishment of regionalized trauma systems and advances in the management of severely injured patients. Trauma-induced coagulopathy has been identified as the most common preventable cause of postinjury mortality.


METHODS
A review of the current literature was performed by collecting PUBMED references related to trauma-induced coagulopathy. Data were then critically analyzed and summarized based on the authors' clinical and research perspective, as well as that reported by other institutions and researchers interested in trauma-induced coagulopathy. A particular focus was placed on those aspects of coagulopathy in which agreement among clinical and basic scientists is currently lacking; these include, pathophysiology, the role of blood components and factor therapy, and goal-directed assessment and management.


RESULTS
Trauma-induced coagulopathy has been recognized in approximately one-third of trauma patients. There is a vast range of severity, and the emergence of viscoelastic assays, such as thrombelastography and rotational thromboelastogram, has refined its diagnosis and management, particularly through the establishment of goal-directed massive transfusion protocols. Despite advancements in the diagnosis and management of trauma-induced coagulopathy, much remains to be understood regarding its pathophysiology. The cell-based model of hemostasis has allowed for characterization of endothelial dysfunction, impaired thrombin generation, platelet dysfunction, fibrinolysis, endogenous anticoagulants such as protein-C, and antifibrinolytic proteins. These concepts collectively compose the contemporary, but still partial, understanding of trauma-induced coagulopathy.


CONCLUSIONS
Trauma-induced coagulopathy is a complex pathophysiological condition, of which some mechanisms have been characterized, but much remains to be understood in order to translate this knowledge into improved outcomes for the injured patient.
Trauma Research Center, Department of Surgery, University of Colorado, Denver, CO, USA Department of Surgery, Denver Health Medical Center, Denver, CO, USA.
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Gonzalez
Trauma Research Center, Department of Surgery, University of Colorado, Denver, CO, USA Department of Surgery, Denver Health Medical Center, Denver, CO, USA Ernest.Moore@dhha.org.
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Moore
Trauma Research Center, Department of Surgery, University of Colorado, Denver, CO, USA Department of Surgery, Denver Health Medical Center, Denver, CO, USA.
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Moore
Trauma Research Center, Department of Surgery, University of Colorado, Denver, CO, USA.
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Chapman
Trauma Research Center, Department of Surgery, University of Colorado, Denver, CO, USA Department of Pediatrics, University of Colorado, Denver, CO, USA Department of Research, Bonfils Blood Center, Denver, CO, USA.
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Silliman
Trauma Research Center, Department of Surgery, University of Colorado, Denver, CO, USA.
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Banerjee
Coagulopathy; ROTEM; fibrinolysis; hemorrhage; thrombelastography; transfusion; trauma