Skip to main content

Advertisement

SpringerLink
Log in

The coagulopathy of trauma

  • Review Article
  • Published:
European Journal of Trauma and Emergency Surgery Aims and scope Submit manuscript

Abstract

Trauma is a leading cause of death, with uncontrolled hemorrhage and exsanguination being the primary causes of preventable deaths during the first 24 h following trauma. Death usually occurs quickly, typically within the first 6 h after injury. One out of four patients arriving at the Emergency Department after trauma is already in hemodynamic and hemostatic depletion. This early manifestation of hemostatic depletion is referred to as the coagulopathy of trauma, which may distinguished as: (i) acute traumatic coagulopathy (ATC) and (ii) iatrogenic coagulopathy (IC). The principle drivers of ATC have been characterized by tissue trauma, inflammation, hypoperfusion/shock, and the acute activation of the neurohumoral system. Hypoperfusion leads to an activation of protein C with cleavage of activated factors V and VIII and the inhibition of plasminogen activator inhibitor-1 (PAI-1), with subsequent fibrinolysis. Endothelial damage and activation results in Weibel–Palade body degradation and glycocalyx shedding associated with autoheparinization. In contrast, there is an IC which occurs secondary to uncritical volume therapy, leading to acidosis, hypothermia, and hemodilution. This coagulopathy may, then, be an integral part of the “vicious cycle” when combined with acidosis and hypothermia. The awareness of the specific pathophysiology and of the principle drivers underlying the coagulopathy of trauma by the treating physician is paramount. It has been shown that early recognition prompted by appropriate and aggressive management can correct coagulopathy, control bleeding, reduce blood product use, and improve outcome in severely injured patients. This paper summarizes: (i) the current concepts of the pathogenesis of the coagulopathy of trauma, including ATC and IC, (ii) the current strategies available for the early identification of patients at risk for coagulopathy and ongoing life-threatening hemorrhage after trauma, and (iii) the current and updated European guidelines for the management of bleeding and coagulopathy following major trauma.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5

Similar content being viewed by others

References

  1. Krug EG, Sharma GK, Lozano R. The global burden of injuries. Am J Public Health. 2000;90:523–6.

    Article  PubMed Central  PubMed  CAS  Google Scholar 

  2. Murray CJ, Lopez AD. Mortality by cause for eight regions of the world: Global Burden of Disease Study. Lancet. 1997;349:1269–76.

    Article  PubMed  CAS  Google Scholar 

  3. Sauaia A, Moore FA, Moore EE, Moser KS, Brennan R, Read RA, Pons PT. Epidemiology of trauma deaths: a reassessment. J Trauma. 1995;38:185–93.

    Article  PubMed  CAS  Google Scholar 

  4. Bellamy RF. The causes of death in conventional land warfare: implications for combat casualty care research. Mil Med. 1984;149(2):55–62.

    PubMed  CAS  Google Scholar 

  5. Holcomb JB, McMullin NR, Pearse L, Caruso J, Wade CE, Oetjen-Gerdes L, Champion HR, Lawnick M, Farr W, Rodriguez S, Butler FK. Causes of death in U.S. Special Operations Forces in the global war on terrorism: 2001–2004. Ann Surg. 2007;245(6):986–91.

    Article  PubMed Central  PubMed  Google Scholar 

  6. Esposito TJ, Sanddal ND, Hansen JD, Reynolds S. Analysis of preventable trauma deaths and inappropriate trauma care in a rural state. J Trauma. 1995;39(5):955–62.

    Article  PubMed  CAS  Google Scholar 

  7. Brohi K, Singh J, Heron M, Coats T. Acute traumatic coagulopathy. J Trauma. 2003;54:1127–30.

    Article  PubMed  Google Scholar 

  8. MacLeod JB, Lynn M, McKenney MG, Cohn SM, Murtha M. Early coagulopathy predicts mortality in trauma. J Trauma. 2003;55:39–44.

    Article  PubMed  Google Scholar 

  9. Maegele M, Lefering R, Yucel N, Tjardes T, Rixen D, Paffrath T, Simanski C, Neugebauer E, Bouillon B; AG Polytrauma of the German Trauma Society (DGU). Early coagulopathy in multiple injury: an analysis from the German Trauma Registry on 8724 patients. Injury. 2007;38:298–304.

    Article  PubMed  Google Scholar 

  10. Maegele M, Yuecel N, Lefering R, Paffrath T, Tjardes T, Bouillon B, Rixen D, Neugebauer E. Early post-traumatic coagulopathy in multiply injury: an analysis on 8,724 patients from the German Trauma Registry Database. Shock. 2006;25(6):56.

    Article  Google Scholar 

  11. Maegele M, Spinella PC, Schöchl H. The acute coagulopathy of trauma: mechanisms and tools for risk stratification. Shock. 2012;38(5):450–8.

    Article  PubMed  Google Scholar 

  12. Gonzalez E, Perkins J, McKinley B, Wade C, Moore F, Holcomb J. Early coagulopathy and massive transfusion (MT) in civilian trauma and combat casualties. Shock. 2006;25(6):88.

    Article  Google Scholar 

  13. Neugebauer EAM, Wayhas C, Lendemans S, Rixen D, Eikermann M, Pohlemann T. Clinical practice guideline: the treatment of patients with severe and multiple traumatic injuries. Dtsch Arztebl Int. 2012;109(6):102–8.

    PubMed Central  PubMed  Google Scholar 

  14. http://www.awmf.org/uploads/tx_szleitlinien/012-019k_S3_Polytrauma_Schwerverletzten-Behandlung_2011-07.pdf.

  15. Spahn DR, Bouillon B, Cerny V, Coats TJ, Duranteau J, Fernández-Mondéjar E, Filipescu D, Hunt BJ, Komadina R, Nardi G, Neugebauer E, Ozier Y, Riddez L, Schultz A, Vincent JL, Rossaint R. Management of bleeding and coagulopathy following major trauma: an updated European guideline. Crit Care. 2013;17(2):R76.

    Article  PubMed  Google Scholar 

  16. Peiniger S, Paffrath T, Mutschler M, Brockamp T, Borgmann M, Spinella PC, Bouillon B, Maegele M; TraumaRegister DGU. The trauma patient in hemorrhagic shock: how is the C-priority addressed between emergency and ICU admission? Scand J Trauma Resusc Emerg Med. 2012;20:78.

    Article  PubMed Central  PubMed  Google Scholar 

  17. Maegele M, Schöchl H, Cohen MJ. An up-date on the coagulopathy of trauma. Shock. 2013 [Epub ahead of print].

  18. Brohi K, Cohen MJ, Ganter MT, Matthay MA, Mackersie RC, Pittet JF. Acute traumatic coagulopathy: initiated by hypoperfusion: modulated through the protein C pathway? Ann Surg. 2007;245(5):812–8.

    Article  PubMed Central  PubMed  Google Scholar 

  19. Chesebro BB, Rahn P, Carles M, Esmon CT, Xu J, Brohi K, Frith D, Pittet JF, Cohen MJ. Increase in activated protein C mediates acute traumatic coagulopathy in mice. Shock. 2009;32(6):659–65.

    Article  PubMed Central  PubMed  CAS  Google Scholar 

  20. Cohen MJ, Kutcher M, Redick B, Nelson M, Call M, Knudson MM, Schreiber MA, Bulger EM, Muskat P, Alarcon LH, Myers JG, Rahbar MH, Brasel KJ, Phelan HA, del Junco DJ, Fox EE, Wade CE, Holcomb JB, Cotton BA, Matijevic N; PROMMTT Study Group. Clinical and mechanistic drivers of acute traumatic coagulopathy. J Trauma Acute Care Surg. 2013;75(Suppl 1):S40–7.

    Article  PubMed  CAS  Google Scholar 

  21. Rezaie AR. Regulation of the protein C anticoagulant and antiinflammatory pathways. Curr Med Chem. 2010;17:2059–69.

    Article  PubMed Central  PubMed  CAS  Google Scholar 

  22. Esmon CT. The roles of protein C and thrombomodulin in the regulation of blood coagulation. J Biol Chem. 1989;264:4743–6.

    PubMed  CAS  Google Scholar 

  23. Noel P, Cashen S, Patel B. Trauma-induced coagulopathy: from biology to therapy. Semin Hematol. 2013;50:259–69.

    Article  PubMed  Google Scholar 

  24. Kutcher ME, Xu J, Vilardi RF, Ho C, Esmon CT, Cohen MJ. Extracellular histone release in response to traumatic injury: implications for a compensatory role of activated protein C. J Trauma Acute Care Surg. 2012;73(6):1389–94.

    Article  PubMed  Google Scholar 

  25. Xu J, Zhang X, Pelayo R, Monestier M, Ammollo CT, Semeraro F, Taylor FB, Esmon NL, Lupu F, Esmon CT. Extracellular histones are major mediators of death in sepsis. Nat Med. 2009;15(11):1318–21.

    Article  PubMed Central  PubMed  CAS  Google Scholar 

  26. Nieuwdorp M, Meuwese MC, Vink H, Hoekstra JB, Kastelein JJ, Stroes ES. The endothelial glycocalyx: a potential barrier between health and vascular disease. Curr Opin Lipidol. 2005;16:507–11.

    Article  PubMed  CAS  Google Scholar 

  27. Johansson PI, Stensballe J, Rasmussen LS, Ostrowski SR. A high admission syndecan-1 level, a marker of endothelial glycocalyx degradation, is associated with inflammation, protein C depletion, fibrinolysis, and increased mortality in trauma patients. Ann Surg. 2011;254:194–200.

    Article  PubMed  Google Scholar 

  28. Lowenstein CJ, Morrell CN, Yamakuchi M. Regulation of Weibel–Palade body exocytosis. Trends Cardiovasc Med. 2005;15:302–8.

    Article  PubMed  CAS  Google Scholar 

  29. Rehm M, Bruegger D, Christ F, Conzen P, Thiel M, Jacob M, Chappell D, Stoeckelhuber M, Welsch U, Reichart B, Peter K, Becker BF. Shedding of the endothelial glycocalyx in patients undergoing major vascular surgery with global and regional ischemia. Circulation. 2007;116:1896–906.

    Article  PubMed  CAS  Google Scholar 

  30. Ostrowski SR, Johansson PI. Endothelial glycocalyx degradation induces endogenous heparinization in patients with severe injury and early traumatic coagulopathy. J Trauma Acute Care Surg. 2012;73:60–6.

    Article  PubMed  CAS  Google Scholar 

  31. Schöchl H, Frietsch T, Pavelka M, Jámbor C. Hyperfibrinolysis after major trauma: differential diagnosis of lysis patterns and prognostic value of thrombelastometry. J Trauma. 2009;67(1):125–31.

    Article  PubMed  Google Scholar 

  32. Kashuk JL, Moore EE, Sawyer M, Wohlauer M, Pezold M, Barnett C, Biffl WL, Burlew CC, Johnson JL, Sauaia A. Primary fibrinolysis is integral in the pathogenesis of the acute coagulopathy of trauma. Ann Surg. 2010;252(3):434–42.

    PubMed  Google Scholar 

  33. Kutcher ME, Cripps MW, McCreery RC, Crane IM, Greenberg MD, Cachola LM, Redick BJ, Nelson MF, Cohen MJ. Criteria for empiric treatment of hyperfibrinolysis after trauma. J Trauma Acute Care Surg. 2012;73:87–93.

    Article  PubMed Central  PubMed  CAS  Google Scholar 

  34. Ives C, Inaba K, Branco BC, Okoye O, Schöchl H, Talving P, Lam L, Shulman I, Nelson J, Demetriades D. Hyperfibrinolysis elicited via thromboelastography predicts mortality in trauma. J Am Coll Surg. 2012;215:469–502.

    Article  Google Scholar 

  35. Raza I, Davenport R, Rourke C, Platton S, Manson J, Spoors C, Khan S, De’ath HD, Allard S, Hart DP, Pasi KJ, Hunt BJ, Stanworth S, MacCallum PK, Brohi K. The incidence and magnitude of fibrinolytic activation in trauma patients. J Thromb Haemost. 2013;11(2):307–14.

    Article  PubMed  CAS  Google Scholar 

  36. Wohlauer MV, Moore EE, Thomas S, Sauaia A, Evans E, Harr J, Silliman CC, Ploplis V, Castellino FJ, Walsh M. Early platelet dysfunction: an unrecognized role in the acute coagulopathy of trauma. J Am Coll Surg. 2012;214(5):739–46.

    Article  PubMed Central  PubMed  Google Scholar 

  37. Kutcher ME, Redick BJ, McCreery RC, Crane IM, Greenberg MD, Cachola LM, Nelson MF, Cohen MJ. Characterization of platelet dysfunction after trauma. J Trauma Acute Care Surg. 2012;73(1):13–9.

    Article  PubMed Central  PubMed  CAS  Google Scholar 

  38. Rourke C, Curry N, Khan S, Taylor R, Raza I, Davenport R, Stanworth S, Brohi K. Fibrinogen levels during trauma hemorrhage, response to replacement therapy, and association with patient outcomes. J Thromb Heamost. 2012;10:1342–51.

    Article  CAS  Google Scholar 

  39. Floccard B, Rugeri L, Faure A, Saint Denis M, Boyle EM, Peguet O, Levrat A, Guillaume C, Marcotte G, Vulliez A, Hautin E, David JS, Négrier C, Allaouchiche B. Early coagulopathy in trauma patients: an on-scene and hospital admission study. Injury. 2012;43(1):26–32.

    Article  PubMed  Google Scholar 

  40. Cosgriff N, Moore EE, Sauaia A, Kenny-Moynihan M, Burch JM, Galloway B. Predicting life-threatening coagulopathy in the massively transfused trauma patient: hypothermia and acidoses revisited. J Trauma. 1997;42(8):857–61.

    Article  PubMed  CAS  Google Scholar 

  41. Wolberg AS, Meng ZH, Monroe DM 3rd, Hoffman M. A systematic evaluation of the effect of temperature on coagulation enzyme activity and platelet function. J Trauma. 2004;56:1221–8.

    Article  PubMed  CAS  Google Scholar 

  42. Meng ZH, Wolberg AS, Monroe DM 3rd, Hoffman M. The effect of temperature and pH on the activity of factor VIIa: Implications for the efficacy of high-dose factor VIIa in hypothermic and acidotic patients. J Trauma. 2003;55:886–91.

    Article  PubMed  CAS  Google Scholar 

  43. Kermode JC, Zheng Q, Milner EP. Marked temperature dependence of the platelet calcium signal induced by human von Willebrand factor. Blood. 1999;94:199–207.

    PubMed  CAS  Google Scholar 

  44. Jurkovich GJ, Greiser WB, Luterman A, Curreri PW. Hypothermia in trauma victims: an ominous predictor of survival. J Trauma. 1987;27:1019–124.

    Article  PubMed  CAS  Google Scholar 

  45. Martini WZ. Coagulopathy by hypothermia and acidosis: mechanisms of thrombin generation and fibrinogen availability. J Trauma. 2009;67:202–9.

    Article  PubMed  CAS  Google Scholar 

  46. Hess JR, Lawson JH. The coagulopathy of trauma versus disseminated intravascular coagulation. J Trauma. 2006;60(6 Suppl):S12–9.

    Article  PubMed  Google Scholar 

  47. Monroe DM. Modeling the action of factor VIIa in dilutional coagulopathy. Thromb Res. 2008;122(Suppl 1):S7–10.

    Article  PubMed  CAS  Google Scholar 

  48. Wafaisade A, Wutzler S, Lefering R, Tjardes T, Banerjee M, Paffrath T, Bouillon B, Maegele M; Trauma Registry of DGU. Drivers of acute coagulopathy after severe trauma: a multivariate analysis of 1987 patients. Emerg Med J. 2010;27(12):934–9.

    Article  PubMed  Google Scholar 

  49. Hess JR, Brohi K, Dutton RP, Hauser CJ, Holcomb JB, Kluger Y, Mackway-Jones K, Parr MJ, Rizoli SB, Yukioka T, Hoyt DB, Bouillon B. The coagulopathy of trauma: a review of mechanisms. J Trauma. 2008;65:748–54.

    Article  PubMed  CAS  Google Scholar 

  50. Harhangi BS, Kompanje EJO, Leebeck FWG, Maas AIR. Coagulation disorders after traumatic brain injury. Acta Neurochirur. 2008;150:165–75.

    Article  CAS  Google Scholar 

  51. Hoyt DB. A clinical review of bleeding dilemmas in trauma. Semin Hematol. 2004;41(1 Suppl 1):40–3.

    Article  PubMed  Google Scholar 

  52. Gómez PA, Lobato RD, Ortega JM, De La Cruz J. Mild head injury: differences in prognosis among patients with a Glasgow Coma Scale score of 13 to 15 and analysis of factors associated with abnormal CT findings. Br J Neurosurg. 1996;10(5):453–60.

    Article  PubMed  Google Scholar 

  53. Wafaisade A, Lefering R, Tjardes T, Wutzler S, Simanski C, Paffrath T, Fischer P, Bouillon B, Maegele M; Trauma Registry of DGU. Acute coagulopathy in isolated blunt traumatic brain injury. Neurocrit Care. 2010;12:211–9.

    Article  PubMed  Google Scholar 

  54. Greuters S, van den Berg A, Franschman G, Viersen VA, Beishuizen A, Peerdeman SM, Boer C; ALARM-BLEEDING Investigators. Acute and delayed mild coagulopathy are related to outcome in patients with isolated traumatic brain injury. Crit Care. 2011;15:R2.

    Article  PubMed Central  PubMed  Google Scholar 

  55. Fabbri A, Servadei F, Marchesini G, Bronzoni C, Montesi D, Arietta L; of the Società Italiana di Medicina d’Emergenza Urgenza Study Group. Antiplatelet therapy and the outcome of subjects with intracranial injury: the Italian SIMEU study. Crit Care. 2013;17:R53.

    Article  PubMed Central  PubMed  Google Scholar 

  56. Laroche M, Kutcher ME, Huang MC, Cohen MJ, Manley GT. Coagulopathy after traumatic brain injury. Neurosurgery. 2012;70(6):1334–45.

    Article  PubMed  Google Scholar 

  57. Maegele M. Coagulopathy after traumatic brain injury: incidence, pathogenesis, and treatment options. Transfusion. 2013;53(Suppl 1):28S–37S.

    Article  PubMed  Google Scholar 

  58. Mann KG, Butenas S, Brummel K. The dynamics of thrombin formation. Arterioscler Thromb Vasc Biol. 2003;23:17–25.

    Article  PubMed  CAS  Google Scholar 

  59. Davenport R, Manson J, De’Ath H, Platton S, Coates A, Allard S, Hart D, Pearse R, Pasi KJ, MacCallum P, Stanworth S, Brohi K. Functional definition and characterization of acute traumatic coagulopathy. Crit Care Med. 2011;39(12):2652–8.

    PubMed Central  PubMed  Google Scholar 

  60. American College of Surgeons, Committee of Trauma. Advanced trauma life support for doctors: student course manual. 8th ed. Chicago: American College of Surgeons; 2008.

    Google Scholar 

  61. Guly HR, Bouamra O, Little R, Dark P, Coats T, Driscoll P, Lecky FE. Testing the validity of the ATLS classification of hypovolaemic shock. Resuscitation. 2010;81(9):1142–7.

    Article  PubMed  CAS  Google Scholar 

  62. Guly HR, Bouamra O, Spiers M, Dark P, Coats T, Lecky FE; Trauma Audit and Research Network. Vital signs and estimated blood loss in patients with major trauma: testing the validity of the ATLS classification of hypovolaemic shock. Resuscitation. 2011;82(5):556–9.

    Article  PubMed  CAS  Google Scholar 

  63. Mutschler M, Nienaber U, Brockamp T, Wafaisade A, Wyen H, Peiniger S, Paffrath T, Bouillon B, Maegele M; TraumaRegister DGU. A critical reappraisal of the ATLS classification of hypovolaemic shock: does it really reflect clinical reality? Resuscitation. 2013;84(3):309–13.

    Article  PubMed  CAS  Google Scholar 

  64. Maegele M, Brockamp T, Nienaber U, Probst C, Schoechl H, Görlinger K, Spinella P. Predictive models and algorithms for the need of transfusion including massive transfusion in severely injured patients. Transfus Med Hemother. 2012;39(2):85–97.

    Article  PubMed Central  PubMed  Google Scholar 

  65. Yücel N, Lefering R, Maegele M, Vorweg M, Tjardes T, Ruchholtz S, Neugebauer EA, Wappler F, Bouillon B, Rixen D; Polytrauma Study Group of the German Trauma Society. Trauma Associated Severe Hemorrhage (TASH)-Score: probability of mass transfusion as surrogate for life threatening hemorrhage after multiple trauma. J Trauma. 2006;60:1228–37.

    Article  PubMed  Google Scholar 

  66. Maegele M, Lefering R, Wafaisade A, Theodorou P, Wutzler S, Fischer P, Bouillon B, Paffrath T; Trauma Registry of Deutsche Gesellschaft für Unfallchirurgie (TR-DGU). Revalidation and update of the TASH-Score: a scoring system to predict the probability for massive transfusion as a surrogate for life-threatening haemorrhage after severe injury. Vox Sang. 2011;100(2):231–8.

    Article  PubMed  CAS  Google Scholar 

  67. Brockamp T, Nienaber U, Mutschler M, Wafaisade A, Peiniger S, Lefering R, Bouillon B, Maegele M; TraumaRegister DGU. Predicting on-going hemorrhage and transfusion requirement after severe trauma: a validation of six scoring systems and algorithms on the TraumaRegister DGU®. Crit Care. 2012;16(4):R129.

    Article  PubMed Central  PubMed  Google Scholar 

  68. Nunez TC, Voskresensky IV, Dossett LA, Shinall R, Dutton WD, Cotton BA. Early prediction of massive transfusion in trauma: simple as ABC (assessment of blood consumption)? J Trauma. 2009;66(2):346–52.

    Article  PubMed  Google Scholar 

  69. Mitra B, Rainer TH, Cameron PA. Predicting massive blood transfusion using clinical scores post-trauma. Vox Sang. 2012;102(4):324–30.

    Article  PubMed  CAS  Google Scholar 

  70. Mutschler M, Brockamp T, Wafaisade A, Lipensky A, Probst C, Bouillon B, Maegele M. ‘Time to TASH’: how long does complete score calculation take to assess major trauma hemorrhage? Transfus Med. 2013 [Epub ahead of print]. doi:10.1111/tme.12089.

  71. Tauber H, Innerhofer P, Breitkopf R, Westermann I, Beer R, El Attal R, Strasak A, Mittermayr M. Prevalence and impact of abnormal ROTEM assays in severe blunt trauma: results of the “Diagnosis and Treatment of Trauma-Induced Coagulopathy (DIA-TRE-TIC) study”. Br J Anaesth. 2011;107:378–87.

    Article  PubMed  CAS  Google Scholar 

  72. Schöchl H, Cotton B, Inaba K, Nienaber U, Fischer H, Voelckel W, Solomon C. FIBTEM provides early prediction of massive transfusion in trauma. Crit Care. 2011;15:R265.

    Article  PubMed Central  PubMed  Google Scholar 

  73. CRASH-2 trial collaborators, Shakur H, Roberts I, Bautista R, Caballero J, Coats T, Dewan Y, El-Sayed H, Gogichaishvili T, Gupta S, Herrera J, Hunt B, Iribhogbe P, Izurieta M, Khamis H, Komolafe E, Marrero MA, Mejía-Mantilla J, Miranda J, Morales C, Olaomi O, Olldashi F, Perel P, Peto R, Ramana PV, Ravi RR, Yutthakasemsunt S. Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo-controlled trial. Lancet. 2010;376:23–32.

    Article  PubMed  CAS  Google Scholar 

  74. Holcomb JB, Jenkins D, Rhee P, Johannigman J, Mahoney P, Mehta S, Cox ED, Gehrke MJ, Beilman GJ, Schreiber M, Flaherty SF, Grathwohl KW, Spinella PC, Perkins JG, Beekley AC, McMullin NR, Park MS, Gonzalez EA, Wade CE, Dubick MA, Schwab CW, Moore FA, Champion HR, Hoyt DB, Hess JR. Damage control resuscitation: directly addressing the early coagulopathy of trauma. J Trauma. 2007;62:307–10.

    Article  PubMed  Google Scholar 

  75. Ketchum L, Hess JR, Hiippala S. Indications for early fresh frozen plasma, cryoprecipitate, and platelet transfusion in trauma. J Trauma. 2006;60(6 Suppl):S51–8.

    Article  PubMed  Google Scholar 

  76. Callum JL, Rizoli S. Plasma transfusion for patients with severe hemorrhage: what is the evidence? Transfusion. 2012;52(Suppl 1):30S–7S.

    Article  PubMed  Google Scholar 

  77. Borgman MA, Spinella PC, Holcomb JB, Blackbourne LH, Wade CE, Lefering R, Bouillon B, Maegele M. The effect of FFP:RBC ratio on morbidity and mortality in trauma patients based on transfusion prediction score. Vox Sang. 2011;101:44–54.

    Article  PubMed Central  PubMed  CAS  Google Scholar 

  78. Rossaint R, Bouillon B, Cerny V, Coats TJ, Duranteau J, Fernández-Mondéjar E, Filipescu D, Hunt BJ, Komadina R, Maegele M, Nardi G, Neugebauer E, Ozier Y, Riddez L, Schultz A, Vincent JL, Spahn DR; the STOP the Bleeding Campaign. The STOP the bleeding campaign. Crit Care. 2013;17(2):136.

    Article  PubMed  PubMed Central  Google Scholar 

  79. Guyatt G, Gutterman D, Baumann MH, Addrizzo-Harris D, Hylek EM, Phillips B, Raskob G, Lewis SZ, Schünemann H. Grading strength of recommendations and quality of evidence in clinical guidelines: report from an American College of Chest Physicians Task Force. Chest. 2006;129:174–81.

    Article  PubMed  Google Scholar 

Download references

Conflict of interest

None are declared.

Author information

Authors and Affiliations

  1. Department of Traumatology, Orthopedic Surgery and Sportsmedicine, Cologne-Merheim Medical Center (CMMC), Private University of Witten/Herdecke, Ostmerheimerstr. 200, 51109, Cologne, Germany

    M. Maegele

  2. Institute for Research in Operative Medicine (IFOM), Private University of Witten/Herdecke, Ostmerheimerstr. 200, 51109, Cologne, Germany

    M. Maegele

Authors
  1. M. Maegele
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to M. Maegele.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Maegele, M. The coagulopathy of trauma. Eur J Trauma Emerg Surg 40, 113–126 (2014). https://doi.org/10.1007/s00068-014-0389-4

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00068-014-0389-4

Keywords

Search

Navigation