During the past 50 years, there have been huge changes in the approach to coagulopathic
bleeding following the treatment of traumatic
hemorrhagic shock (HS). Treatment during the 1960s consisted primarily of physiologic saline (balanced
electrolyte solution [
BES]) and whole blood supported with
sodium bicarbonate for
acidosis. Subsequent coagulopathy was assumed to be caused by lack of the labile factors (FV and FVIII) which were then replaced by fresh whole blood. The decade of 1970s saw the implementation of component
therapy by the American Blood Banking Association so that HS was treated with
BES and packed red blood cells (RBC). A new paradigm had to be learned to determine when and how much fresh frozen plasma (FFP) was needed to restore all
coagulation factors. By the end of 1970s, most trauma centers were supplementing
BES and RBC with FFP in patients with severe
injuries requiring massive transfusion of more than one circulating blood volume. By the 1980s, the use of FFP skyrocketed, creating a crisis for the American Blood Banking Association. This led to a National Institute of Health Consensus Development Conference which concluded that FFP should be given to only those patients who had a documented coagulopathy as evidenced by a prolongation of the prothrombin time and the partial thromboplastin time. Restriction of FFP replacement to patients with proven coagulopathy
after treatment for HS led to postoperative
bleeding which was sometimes fatal. During the 1990s, uncontrolled clinical studies and rigorously controlled animal studies showed that FFP should be administered before the onset of proven coagulopathy with prolongation of the prothrombin time and partial thromboplastin time. Later during the 1990s, recombinant-
activated factor VII (FVIIa) was purported to provide quicker hemostasis in patients treated with HS. The efficacy of FVIIa supplementation is still being assessed. During the 2010s, the military surgeons promoted the use of a
hemostatic regimen which consists of platelets, RBC, and FFP in a 1:1:1 ratio. This recommendation is still being assessed with different authors reporting benefits and detriments. Throughout these years, an unusual entity of
disseminated intravascular coagulation (
DIC) was known to complicate the
resuscitation of seriously injured patients with HS. This syndrome was typically seen
after treatment of HS and was associated with abnormal
bleeding plus
respiratory failure and
renal failure thought to be caused by a combination of micro- and macrothromboses. The early studies suggested that the best
therapy for breaking this viscous cycle of
bleeding and intravascular coagulation was by infusing fresh whole blood. The theoretical benefits of administering
heparin to prevent the
thrombosis and
epsilon-aminocaproic acid to enhance lysis have not proven beneficial.
DIC is also seen in association with toxic exposures, including
snake bites.
Epsilon-aminocaproic acid may be beneficial in that setting. Many of the intricate understandings of
DIC remain elusive and are still being studied.