Coagulopathy

Learning objectives

Coagulopathy is a condition in which the blood’s ability to coagulate (form clots) is impaired
Leading to a tendency toward prolonged or excessive bleeding and occurring spontaneously or following an injury
Caused by:
- Genetic conditions such as hemophilia and Von Willebrand disease
- Acquired factors: anticoagulant medications (warfarin), the continued use of antibiotics, liver disease, or disseminated intravascular coagulation
Activation of coagulation will lead to consumption of clotting factors, particularly factor V and fibrinogen, leading to a consumptive coagulopathy

Obtain a blood sample for a full coagulation screen
Perform near-patient testing such as ROTEM or TEG
Consider permissive hypotension in patients with moderate bleeding
Perform massive volume resuscitation in a patient with severe hypovolemic shock
Limit crystalloid and colloid infusions as this leads to acidosis, hypothermia and coagulopathy
Transfuse red blood cells → hemoglobin target is between 7-9 dL/L
Administer fresh frozen plasma, platelets, cryoprecipitate, and concentrated red cells, depending on clotting results and blood loss
Correct hyperfibrinolysis with tranexamic acid (see also blood transfusion)
Avoid volatile anesthetics as they lead to vasodilation
Administer multimodal analgesia (opioids, NMDA glutamate receptor antagonists)
Regional anesthesia is not indicated as it takes too much time and could mask compartment syndrome
Avoid hypothermia as this worsens coagulopathy
- With passive rewarming, active external rewarming, and active internal rewarming
- Hypothermia impairs thrombin generation
- Hypothermia contributes to platelet dysfunction
Consider complications associated with plasma administration such as TRALI, sepsis, and ABO incompatibility

TXA, tranexamic acid; PCC, Prothrombin Complex Concentrates