Changes in Coagulation following Brain Injury.

Traumatic brain injury (TBI) is a worldwide public health concern due to increasing mortality, affecting around 10 million patients per year. A wide variety of clinical presentations are a function of the magnitude of injury and the anatomical perturbation of the brain parenchyma, supporting structures, and cerebral vasculature, with subsequent alteration of the blood-brain barrier. These disturbances correspond with the evolution of intracerebral hemorrhage and clinical outcomes. The associated hemostatic alterations associated with TBI are caused by the disruption of the delicate balance between bleeding and thrombosis formation, which can exacerbate initial injury. TBI-associated coagulopathy is a function of a cross-talk between coagulation and inflammation, with varying influences on the immunomodulation and regulation of coagulation that occur on platelets and the endothelium of injured TBI patients. In addition to the severity of initial injury, the following factors modulate the hemocoagulative response to TBI: time from the onset of injury to treatment, age, gender, catecholamine secretion, platelet dysfunction, endotheliopathy, premorbid anticoagulation, fibrinolysis, tissue factor, and activated protein C contribution. All these entities are intertwined and influence the pathologic evolution of TBI. These factors have implications for therapeutic options such as the choice of blood components for transfusion and hemostatic agents such as tranexamic acid. Monitoring hemostatic changes of TBI patients requires an understanding of these interactions between immunology and coagulation, which can be discerned by point-of-care viscoelastic testing with specific limitations. This review considers the implications of these interrelated influences on the evaluation of coagulopathy in TBI.

Whole Blood for Civilian Urban Trauma Resuscitation: Historical, Present, and Future Considerations.

Whole blood (WB) has been used for more than a century for far-forward combat resuscitation. Following the Iraq/Afghanistan combat, maritime, and austere environment use of WB for the resuscitation of severely hemorrhaging patients, there has been an increasing use of WB for the civilian urban resuscitation environment population. The impetus for this was not just improved outcomes in far-forward hospitals, which had different populations and different needs than the civilian urban population, but also an application of the lessons suggested by recent 1:1:1 plasma:platelets:packed red cells fixed-ratio studies for patients with massive transfusion needs. Mechanistic, logistic, and standardization concerns have been addressed and are evolving as the WB project advances. A small number of studies have been published on WB in the civilian urban trauma population. In addition, European experience with viscoelastic testing and resuscitation with fibrinogen and prothrombin complex concentrate has provided another viewpoint regarding the choice of resuscitation strategies for severely bleeding trauma patients in urban civilian environments. There are randomized controlled trials in process, which are testing the hypothesis that WB may be beneficial for the civilian urban population. Whether WB will improve mortality significantly is now a matter of intense study, and this commentary reviews the history, mechanistic foundations, and logistical aspects for the use of WB in the civilian trauma population.

Targeted Thromboelastographic (TEG) Blood Component and Pharmacologic Hemostatic Therapy in Traumatic and Acquired Coagulopathy.

Trauma-induced coagulopathy (TIC) is a recently described condition which traditionally has been diagnosed by the common coagulation tests (CCTs) such as prothrombin time/international normalized ratio (PT/INR), activated partial thromboplastin time (aPTT), platelet count, and fibrinogen levels. The varying sensitivity and specificity of these CCTs have led trauma coagulation researchers and clinicians to use Viscoelastic Tests (VET) such as Thromboelastography (TEG) to provide Targeted Thromboelastographic Hemostatic and Adjunctive Therapy (TTHAT) in a goal directed fashion to those trauma patients in need of hemostatic resuscitation. This review describes the utility of VETs, in particular, TEG, to provide TTHAT in trauma and acquired non-trauma-induced coagulopathy.

Association of clinical signs and symptoms of Ebola viral disease with case fatality: a systematic review and meta-analysis.

BACKGROUND: Ebola virus disease (EVD) is a public health emergency of international concern. There is limited laboratory and clinical data available on patients with EVD. This is a meta-analysis to assess the utility of clinical signs, symptoms, and laboratory data in predicting mortality in EVD. AIM: To assess the utility of clinical signs, symptoms, and laboratory data in predicting mortality in EVD. METHOD: Study selection criterion: EVD articles with more than 35 EVD cases that described the clinical features were included. Data collection and extraction: Articles were searched in Medline, PubMed, Ovid journals, and CDC and WHO official websites. STATISTICAL METHODS: Pooled proportions were calculated using DerSimonian Laird method (random effects model). RESULTS: Initial search identified 634 reference articles, of which 67 were selected and reviewed. Data were extracted from 10 articles (N=5,792) of EVD which met the inclusion criteria. Bleeding events (64.5% vs. 25.1%), abdominal pain (58.3% vs. 37.5%), vomiting (60.8% vs. 31.7%), diarrhea (69.9% vs. 37.8%), cough (31.6% vs. 22.3%), sore throat (47.7% vs. 19.8%), and conjunctivitis (39.3% vs. 20.3%) were more often present in pooled proportion of fatal cases as compared to EVD survivors. CONCLUSIONS: Clinical features of EVD that may be associated with higher mortality include bleeding events, vomiting, diarrhea, abdominal pain, cough, sore throat, and conjunctivitis. These patients should be identified promptly, and appropriate management should be instituted immediately.