Prediction of acute traumatic coagulopathy and massive transfusion - Is this the best we can do?

Every year over 2 million people die from bleeding after major rauma. As a potentially preventable cause of death, trauma haemrrhage is an important area for research and innovation. There ave been dramatic changes in practice recently, including the ntroduction of ‘haemostatic resuscitation’ protocols.1 Previously, esuscitation of haemorrhagic shock was focused on restoring irculating volume and organ perfusion. Coagulopathy was conidered a consequence of dilution or loss of clotting factors and herefore a late event in the clinical course. Replacement of coaglation factors was considered to be required relatively late in the linical course and only after the administration of large volumes of ed cell transfusions. This approach was challenged with the discovry of acute traumatic coagulopathy (ATC), which develops within inutes of injury, exacerbates haemorrhage and is associated with igh mortality rates.2 The new haemostatic resuscitation protocols arget ATC, giving large doses of plasma and platelet therapies much arlier and concurrent with red cell transfusions. Early studies sugest this approach may significantly improve outcomes in trauma aemorrhage. For these protocols to be effective, bleeding patients must be dentified early in their clinical course, as there are logistic issues n the rapid provision of plasma and platelet transfusions. There is n intrinsic conflict between the need for more blood products to e delivered as quickly as possible, and the importance of avoiding nnecessary transfusions or the waste of a precious resource. Idelly therefore we should be able to identify rapidly people who ill require large blood product transfusions. In practice this is ot a straightforward process. In a multicentre study of over five housand patients, variables that were most predictive of massive ransfusion were admission systolic blood pressure, base deficit, njury severity score and prothrombin time.3 However, only the rst two of these are readily available on admission, and a predicive tool using these parameters achieved only a 50–70% specificity t a 90% sensitivity threshold. Other massive transfusion prediction ools have had similar performance, and while attractive in their implicity, will still result in late activation or over transfusion in any cases.4–6 As admission coagulopathy is highly predictive of subsequent ransfusion requirements, the early diagnosis of ATC would signifcantly improve the activation accuracy of massive haemorrhage rotocols. Additionally, the administration of fresh frozen plasma o patients without coagulopathy has been shown to have no addiional benefits on clotting function.7 Traditional laboratory tests f coagulation, such as the prothrombin time, are not suitable for uiding transfusion therapy. Results are not available in a use-