What is the initial approach to managing systemic coagulopathies?

Initial Approach to Systemic Coagulopathies

Immediately initiate combined coagulation monitoring with standard laboratory tests (PT/INR, APTT, fibrinogen, platelet count) and viscoelastic testing (TEG/ROTEM) upon hospital admission, as early goal-directed correction of coagulopathy reduces transfusion requirements, multiorgan failure, and mortality. 1

Immediate Assessment and Monitoring

Laboratory Workup

• Obtain PT/INR, APTT, fibrinogen level, and platelet count immediately upon presentation, recognizing that PT/INR only monitors approximately 4% of thrombin production and can appear falsely normal while severe coagulopathy exists 2
• Add viscoelastic testing (TEG/ROTEM) alongside standard tests to provide real-time assessment 30-60 minutes faster than conventional testing and detect coagulopathy missed by PT/APTT 1, 2
• Measure ionized calcium and correct to normal range as hypocalcaemia is frequently present and impairs coagulation 1
• Check blood lactate and base deficit to estimate bleeding severity and tissue hypoperfusion 1
• Repeat testing frequently during active bleeding as coagulopathy evolves rapidly and fibrinogen drops first and fastest 2

Critical Pitfall

Do not wait for laboratory confirmation before initiating treatment in patients with life-threatening hemorrhage—clinical assessment of shock (pulse >100 bpm, systolic BP <100 mmHg) should trigger immediate empiric therapy 1

Initial Resuscitation Strategy

For Expected Massive Hemorrhage (Choose One Strategy)

Option 1: Concentrate-Based Approach

• Administer fibrinogen concentrate 3-4 g (or cryoprecipitate 15-20 units) plus packed red blood cells as initial therapy 1
• This approach allows faster correction of hypofibrinogenemia without delays in achieving target ratios 1

Option 2: Fixed-Ratio Blood Product Strategy

• Transfuse FFP:platelets:pRBC in 1:1:1 to 1:1:2 ratio until coagulation testing results available 1
• The 1:1:1 ratio improves hemostasis and reduces exsanguination deaths compared to 1:1:2 1

Tranexamic Acid Administration

• Give tranexamic acid 1 g IV over 10 minutes immediately to bleeding patients or those at risk of significant bleeding, followed by 1 g infused over 8 hours 1
• Administer within 3 hours of injury for maximum benefit; do not await viscoelastic assessment results 1
• Earlier administration (<1 hour from injury) shows greater mortality reduction than delayed treatment 1

Goal-Directed Correction Phase

Fibrinogen Management

• Target fibrinogen >1.5-2.0 g/L using repeat doses of fibrinogen concentrate (3-4 g) or cryoprecipitate guided by viscoelastic monitoring and laboratory values 1
• Fibrinogen is the first coagulation factor to reach critical levels (after ~150% blood loss) and requires priority correction 2

Fresh Frozen Plasma

• Use FFP only when PT/APTT >1.5 times normal and/or viscoelastic evidence of coagulation factor deficiency 1
• Avoid FFP for isolated hypofibrinogenemia correction—use fibrinogen concentrate or cryoprecipitate instead 1

Prothrombin Complex Concentrate

• Administer PCC based on viscoelastic evidence of delayed coagulation initiation when functional fibrinogen levels are normal 1
• For warfarin reversal in bleeding trauma patients, give PCC 25-50 U/kg early 1

Platelet Transfusion

• Maintain platelet count >50 × 10⁹/L in ongoing bleeding 1
• Maintain platelet count >100 × 10⁹/L in traumatic brain injury 1, 2
• Initial dose: 4-8 single platelet units or one apheresis pack 1

Calcium Replacement

• Monitor ionized calcium continuously during massive transfusion and maintain within normal range using calcium chloride 1

Anticoagulant Reversal

Vitamin K Antagonists (Warfarin)

• Reverse with PCC 25-50 U/kg immediately in bleeding patients with elevated INR 1, 3
• Vitamin K 2.5-10 mg (up to 25 mg) IV/SC provides definitive reversal but takes 6-8 hours for effect 3

Direct Oral Anticoagulants

• For factor Xa inhibitors (rivaroxaban, apixaban): Measure anti-factor Xa activity and give PCC 25-50 U/kg if detected 1
• For factor IIa inhibitors (dabigatran): Consider hemodialysis or factor VIII inhibitor bypassing activity, as PCC is inefficient 1

Rescue Therapy

Recombinant Factor VIIa

• Consider rFVIIa only after failure of all other measures: surgical bleeding control, best-practice blood component therapy (Hct >24%, platelets >50 × 10⁹/L, fibrinogen >1.5-2.0 g/L), antifibrinolytics, and correction of acidosis, hypothermia, and hypocalcemia 1
• Do not use rFVIIa in isolated traumatic brain injury with intracranial hemorrhage 1

Temperature and Metabolic Correction

• Initiate early warming measures to achieve and maintain normothermia as hypothermia impairs coagulation enzyme kinetics 1
• Correct pH to >7.2 as acidosis significantly reduces response to hemostatic therapies 1

Common Pitfalls to Avoid

• Do not rely on single PT/APTT measurements—they can appear normal while overall coagulation is severely impaired, particularly in early traumatic coagulopathy 2
• Do not delay fibrinogen supplementation—waiting for clinical coagulopathy before testing leads to delayed intervention and worse outcomes 2
• Do not administer FFP for hypofibrinogenemia—it is inefficient and delays achieving therapeutic fibrinogen levels 1
• Do not give rFVIIa as first-line therapy—it requires adequate platelets, fibrinogen, normal pH, and normothermia to function 1