Coagulopathy after adult and pediatric trauma

Over the past decades, our understanding of the development, diagnosis and treatment of coagulopathy after trauma has dramatically increased. In adults, perturbations in coagulation after trauma have been commonly observed and substantial research in this area has been conducted. However, few scientific efforts have focused on the pediatric trauma population. This is concerning, as trauma is the leading cause of death amongst children between age 1-18 years. Exsanguination is the most important contributing factor of acute-phase mortality after injury and the development of coagulation abnormalities exacerbates the bleeding. Acute traumatic coagulopathy (ACT) has been described as an early endogenous process, driven by a combination of tissue injury and shock contributing to worse outcome and increased mortality. In adults, endothelial activation of protein C is a central mechanism of ATC leading to rapid anticoagulation and fibrinolysis. However, understanding of the role and mechanisms of coagulopathy affecting the pediatric patient remains limited. In order to evaluate coagulation status after trauma, accurate interpretation of testing modalities is a prerequisite. Conventional coagulation tests (eg, PT, aPTT, INR, and fibrinogen) have been proven time-consuming and insufficient as they merely monitor the initiation phase of coagulation. Focus is increasingly directed on coagulation monitoring devices that assess the viscoelastic properties of whole blood and the function of platelets. In adults, these assays have demonstrated promising results in their ability to identify coagulation abnormalities and guide treatment. While ACT requires prompt treatment, the risk for coagulation abnormalities remains in the days following injury. The rate of preventable deaths due to acute hemorrhage has significantly decreased in the past years, but an increase in ICU mortality comes as a result of inflammatory syndromes and hypercoagulability later on. In these settings, clinicians are often challenged with the decision to administer thromboprophylaxis due to the increased risk of hemorrhage, specifically in patients with traumatic brain injury. This thesis originated from a knowledge gap in the development, diagnosis and management of coagulopathy after trauma, primarily in the pediatric population.