American College of Surgeons Committee on Trauma

Abstract

Transfusion in trauma has undergone a paradigm shift in the past decade. Previous resuscitation strategies for trauma haemorrhage featured early administration of large volumes of crystalloids with subsequent delivery of plasma to treat a gradually evolving coagulopathy due to haemodilution, hypothermia and acidosis. However, the identification of an acute endogenous coagulopathy in trauma victims triggered a re-evaluation of this strategy. Acute traumatic coagulopathy (ATC) occurs rapidly after severe injury as a product of combined tissue damage and hypoperfusion. A series of retrospective observational studies have identified that trauma patients receiving early (and high-dose) administration of haemostatic blood products (including plasma, fibrinogen and platelets), rather than crystalloids, may have better survival with reduced morbidity. This has been attributed to better prevention and/or treatment of ATC. Most western trauma centres now utilise a massive haemorrhage protocol to guide rapid delivery of these blood products in prespecified ratios. However, the re-emergence of thromboelastography is offering promise to refine this formulaic approach and replace it with patient-tailored algorithms. This chapter will describe the recent evolution in trauma transfusion with focus on our developing understanding of the coagulopathy driving these changes.