Shock Syndromes II

There is no consensus regarding values defining traumatic coagulopathy, and various definitions exist.

However, it is commonly defined as an increase in standard plasma-based coagulation tests above

normal limits not associated with antiplatelet or anticoagulation therapy (aPTT, prothrombin time [PT],

and INR). These include PT greater than 18 seconds, INR greater than 1.5, aPTT greater than 60

seconds, or any of these values at a threshold of 1.5 times the laboratory reference value. The prevalence

of prolonged PT is higher, but prolongation of the PTT is more specific. In a multicenter, observational

study, an INR-based definition of acute coagulopathy (INR greater than 1.5) was significantly

associated with death (odds ratio [OR] 1.88; p<0.001), venous thromboembolism (OR 1.73; p<0.001),

and multiorgan failure (OR 1.38; p=0.02).

70% mortality rate, which likely plays a significant role in preventable deaths caused by hemorrhage

Pathophysiology of ATC is multifactorial:

Inadequate tissue perfusion as the result of hypovolemia

Subsequent cell hypoxia, anaerobic respiration, and metabolic acidosis

Thrombin–thrombomodulin-complex generation caused by the tissue injury and the activation of

anticoagulant and fibrinolytic pathways

Severe systemic hypothermia is associated with decreases in the enzymatic activity of clotting

factors.

Coagulopathy, acidosis, and hypothermia—known as the “lethal triad”—exacerbate one another,

rapidly leading to death if not reversed.

The DISPARITY study investigated whether sex differences existed in Surviving Sepsis Campaign

resuscitation bundle completion, completion of individual bundle elements, or sepsis mortality. The

study aimed to identify potential disparities in ED care for patients with sepsis on the basis of sex.

The study reported that women with coagulopathy (INR greater than 1.5) may have received less

aggressive care than men. The study showed a specific association of coagulopathy with bundle

noncompletion in women (but not men) with an adjusted odds ratio of 0.49 (95% CI, 0.25–0.94).

However, the analysis of sex-specific factors in survival showed a trend toward an association

between bundle completion and survival in women but not men.

Characterization of ATC

α = α- angle; K = kinetics; LY30 = lysis at 30 minutes; MA = maximum amplitude; R = reaction time.