Trauma Coagulopathy

Trauma causes at least 5.8 million deaths worldwide annually, accounting for 1 in 10 of all global deaths. Uncontrolled bleeding within 24 hours after trauma is the leading cause of death in trauma patients, and about one-third of patients present with trauma-induced coagulopathy on admission. Fatal severe traumatic hemorrhage is the most common preventable factor contributing to death. Tranexamic acid (TXA), a synthetic lysine derivative, competitively inhibits plasminogen activation, preventing fibrin clot breakdown and thereby enhancing hemostasis and reducing blood loss. Randomized controlled trials such as CRASH-2 have confirmed that TXA significantly reduces mortality in patients with severe traumatic bleeding. TXA has therefore become a cornerstone of traumatic hemorrhage treatment, with current international guidelines recommending 1 g intravenous bolus (over \>10 minutes) plus 1 g intravenous maintenance infusion (over 8 hours). However, severe traumatic hemorrhage is typically managed in high-pressure, chaotic battlefield or emergency settings, where this complex, time-sensitive, multi-step divided regimen is difficult to fully execute in real-world practice. The omission rate of the second maintenance infusion is particularly high, reaching up to 67% during prehospital-to-hospital handover. Rowell et al. showed that even with a strict research protocol, completion of the planned 8-hour in-hospital maintenance infusion was only about 70%. Previous pharmacokinetic studies found that without the second maintenance dose, 21% of patients receiving an initial 1 g dose had already failed to achieve effective plasma concentrations at hospital admission (approximately 1.5 hours post-dose). Thus, the inherent difficulty of fully executing the divided regimen may prevent patients from receiving the full benefits of TXA. To address this, a simplified regimen of a single 2 g loading dose without maintenance infusion has been recommended in recent expert consensus statements, especially for prehospital or battlefield settings. However, these recommendations were mainly based on the 2020 Rowell et al. randomized controlled study, whose exploratory analysis suggested potential mortality reduction with the simplified regimen. That study enrolled patients with traumatic brain injury and had limited statistical power, so evidence on the efficacy and safety of the simplified regimen in patients with severe traumatic hemorrhage remains lacking. Based on the pharmacokinetic study by Grassin-Delyle et al., a single 2 g loading dose is hypothesized to maintain effective concentrations during the peak fibrinolytic period (within 3 hours post-injury), while the transient peak plasma concentration remains well below the toxicity threshold of 500 μg/mL. We therefore hypothesize that, in patients with severe traumatic hemorrhage, the simplified TXA regimen is non-inferior to the divided regimen in efficacy, including bleeding control. However, the primary limitation of a large randomized controlled trial to verify this hypothesis is that safety concerns regarding the simplified regimen due to higher transient plasma concentrations compared with the divided regimen have not been clearly resolved. Previous systematic reviews concluded that safety events such as thrombosis and seizures are dose-dependent, and that a total daily dose not exceeding 2 g is safe. Previous pharmacokinetic studies also suggest that the transient peak concentration of the simplified regimen should be well below the toxicity threshold. Although expert consensus has recommended the simplified regimen, suggesting it can be considered safe, studies directly comparing the two regimens are lacking, particularly regarding whether the simplified regimen increases safety risks when the total dose is identical. Before conducting a larger, more definitive efficacy trial, it is also important to evaluate recruitment rates, protocol adherence, accurate sample size estimation, and other potential barriers. For these reasons, we designed this pilot study, primarily to evaluate the safety of the simplified TXA regimen compared with the divided regimen in patients with traumatic hemorrhagic shock, and the feasibility of a subsequent randomized controlled trial.

Emergency medical service (EMS) vehicles are exposed to a wide range of environmental conditions, including high temperatures during summer months. These conditions may affect the stability and quality of medications and blood products carried for emergency treatment. This observational study aims to evaluate the stability of human fibrinogen concentrates and human plasma proteins (Octaplas) when stored under routine operating conditions in a ground-based EMS ambulance in Graz, Austria. Drug samples will be analyzed monthly over a four-month period and compared with reference samples stored under recommended conditions. In addition, temperature inside the storage containers and the vehicle will be continuously monitored. The study will assess whether prolonged exposure to real-world prehospital storage conditions affects product stability and whether any changes are associated with environmental factors. The findings may help determine whether current storage practices in EMS vehicles are adequate for maintaining the quality of these blood coagulation products.

Background: Why This Study Matters When someone suffers a severe injury (like from a car crash), they can bleed heavily. One complication doctors often face is something called Trauma-Induced Coagulopathy (TIC). This is a condition where the blood doesn't clot properly, making bleeding worse. The reasons behind TIC are complicated and not fully understood. One important substance involved is fibrinogen, a protein that helps blood clot. Low levels of fibrinogen are often the first sign of TIC and tend to be linked with how bad the injury is. Because of this, doctors have been giving trauma patients extra fibrinogen early on, hoping it will help them survive. However, a recent large study (called CRYOSTAT-2) showed that giving high doses of fibrinogen to all trauma patients didn't actually help reduce deaths. This suggests that not everyone needs it-only patients with very low fibrinogen levels (below 1.5 grams per liter) should get it. The problem is: it currently takes 30 to 45 minutes to get fibrinogen test results. In emergency situations, that's too slow. So doctors have been guessing who needs it, which might not always be the best approach. What This Study Aims to Do This new study wants to see if a faster, bedside test-called a point-of-care (POC) fibrinogen test-can be used in the Emergency Department (ED) during trauma resuscitations. Main Goals: Feasibility: Can the test be done quickly and easily during emergency care? Usefulness: If the fast test had been available, would doctors have made different decisions-like giving or not giving fibrinogen? And would that have changed outcomes for the patients? Study Details Feasibility Study: To see if the test is practical during trauma care. Retrospective Cohort Study: To look back at patients and see if early test results could have changed decisions or outcomes. Who's In the Study? Adults over 16 who arrive at the ED with serious trauma and for whom the hospital's Massive Transfusion Protocol was activated (meaning they had major bleeding). They must have received at least one unit of blood. How the Study Will Work The Test: A small amount of blood (0.15 ml) will be taken from blood that's already being drawn for routine care-so no extra blood draws are needed. The POC test (called qLabs Fib) will be done at the same time as standard lab tests. Important Note: Doctors won't make decisions based on this fast test for now. It's just being tested for feasibility. Nurses will note how long the test takes and if they had any trouble using it. Later, researchers will look back at the data to see: * What the fibrinogen levels were. * Whether the fast results could have helped guide better treatment. * If outcomes like how much blood was given or survival were affected. Why It Matters If the fast test works well, it could lead to * Faster, more accurate treatment in trauma cases. * Less unnecessary use of fibrinogen, saving resources and avoiding possible side effects. * Better outcomes for patients by tailoring treatment to their actual needs.

The investigators will evaluate the implementation of a treatment bundle (Fibrinogen, Plasma and Tranexamic Acid)

Traumatic coagulopathy is a complex, multifactorial event that occurs in 20-30% of patients on admission. It increases mortality, and its treatment is one of the main priorities in the early management of severely injured patients. Diagnosis of coagulopathy has traditionally been based on conventional coagulation tests (CCTs), which provide an assessment of patients' coagulation in over 60 minutes. Over the past fifteen years, viscoelastic tests (VETs) have been proposed, providing a more rapid result (≤ 10 min) and can guide the administration of labile blood products (LBP). Various studies, mainly retrospective, have shown that the use of VETs is associated with a significant reduction in the use of LBP and the incidence of massive transfusions (MT). For example, it has been showed that the use of VETs was accompanied by a reduction in the administration of LBP and more particularly of RBC (Red blood cell concentrate) (4.8 units vs. 1.9 units). The investigators obtained the same result on a larger number of patients, with a further reduction in the administration of other LBP and in the incidence of MT (33% vs. 8%, p\<0.01). However, the main limitation of these 2 studies is that the results may not have been due solely to the use of ROTEM, but rather to a care package combining the use of ROTEM with the administration of tranexamic acid and the implementation of Damage Control Surgery techniques. To avoid this methodological criticism, we recently compared 2 contemporary French cohorts (2012-2019), in which patients had similar management of traumatic injuries, with the exception of the type of coagulation tests: CCT vs. VET. The use of VET s was associated with an increase in the number of patients alive at 24h without MT (76% vs. 55%, p\<0.001), but also with a sharp reduction in the administration of all LBPs. This composite criterion associating the occurrence of a MT with survival at 24 hours after hospital admission was the primary endpoint of the randomized iTACTIC study. iTACTICS was published in 2021, and aimed to compare in severely injured patients 2 strategies for the diagnosis and treatment of coagulopathies, based on CCT in one arm and VET in the other. In this work, the use of VET was not associated with an improvement in the proportion of patients alive at 24 hours without MT (64% vs. 67%, OR 1.15, CI95%: 0.8-1.7), nor with any of the other criteria studied. The main limitation of this study is that less than a third of the patients included had a coagulopathy on admission. The probability of receiving LBP was therefore low. In the subgroup of the most severe patients, an improvement in the primary endpoint was observed for patients randomized to the VET group. The small sample size and subgroup analysis, however, limited the significance of this result. All these elements suggest that it is necessary : * to use a composite endpoint rather than a single endpoint (mortality) for the evaluation of VET-based strategies, combining early mortality with the occurrence of a transfusion event. * conduct a randomized trial comparing the use of VETs with that of CCTs in trauma patients with a high probability of coagulopathy on admission to hospital.

This prospective observational study aims to investigate the ability of advanced ROTEM analysis using Principal Component Analysis (PCA) to detect early signs of disseminated intravascular coagulation (DIC) and trauma-induced coagulopathy (TIC) in hospitalized patients with sepsis or trauma. Standard coagulation tests and ROTEM measurements will be collected and analyzed in relation to clinical outcomes.

Trauma is an important global public health problem and is the leading cause of death in people under 40 years old. Studies have shown that early prehospital administration of TXA 1 g intravenously followed by a continuous infusion of 1 g tranexamic acid (TXA) over 8 hours ( 1+1 regimen) is effective in reducing mortality in trauma patients, but there is a residual risk of death. This clinical study utilized real-time dynamic monitoring of coagulation fibrinolytic status in trauma patients using thromboelastography (TEG) to assess the need for a second or even multiple administrations of TXA (1+X regimen) in addition to the administration of 1 g of TXA intravenously and to compare the two mortality rates, thus guiding the early and precise use of TXA in trauma patients to potentially reduce mortality in trauma patients while decreasing thromboembolic risk. The present study is an optimization and addition to the TXA 1+1 regimen. Currently, no relevant studies have been reported. This study has important clinical significance for standardizing the early and precise use of TXA in trauma patients and improving the effectiveness and safety of TXA.