Coagulopathy in Trauma

including in Severe head injury

DR. MZ. Arifin, dr.,SpBS

Akhmad Imron,
dr.,SpBS.,MKes.
Cases
Mr. R/M/25 yo/30480
MRS: 2-9-2011
CC : Decrease of unconsciousness
History :
3 hours prior to admission, when he was riding motorcycle at Malangbong
area with helmet, Suddenly his motorcycle struck by a another motorcycle. He
fell down and his head hit the ground. History of unconscious (+), vomiting (+),
bleeding from ear (-), nose (+) and mouth (+). He was brought directly to
Sukamerang PHC and than refered to Emergency Hasan Sadikin Hospital.
Primary Survey :
A : Gurgling intubation clear, c-spine control
B : RR : 20x/mnt, symetrical shape and movement, VBS right = left
C : P : 76x/mnt, BP : 110/70 mmHg
D : GCS : E1M2VT = 3T
Pupil : round, equal ODS 5 mm, LR /
Motor : no paresis

Secondary survey :
At Mid frontal : hematom (+), lacerated wound 3x0,5 cm, based on subcutis
at Nostril : Rhinorhea (+)
At nasal area : defromity (+)
At upper dentoalveolar : deformitas (+)
At (R) Femur : Deformitas (+), Hematom (+)
Skull x ray : Dentoalveolar fracture + nasal fracture
Cervical x ray : no fracture
line
Chest x ray : within normal
limit
Laboratory Finding:

Hb 10,3 lakta 4,5 PH 7,43 PH 7,44

t 8 5
Ht 31
ur 27 PCO 25,5 PCO 31,5
Leuko 21.300
2 2
kr 0,82
Trombo 48.000
PO2 50,9 PO2 221,
sit GDS 315
9
HCO 17,5
Na 137
3 HCO 19,5
K 3,2 3
TCO 18,3
2 TCO 18,4
2
BE -7,1
BE 4,1
Sat 88,1
Sat 98,0
WD/Severe Head Injury (GCS 3T) + Skull base fracture at
anterior fossa + Fracture dentoalveolar + close Fracture Right
Femur
Th/ Closed Observation (NC)
Plan Eyelet (Oral Surgery)
Plan ORIF Elective (Orthopeady)
Th/ Closed observation
17.30 Patient admission, ABC Clear BP 110/70, HR 100 RR 30 GCS E1M2VT=4T pupil equal 5mm ODS, RC -/- motoric parese -/-,
19.30 Patient was X-ray foto GCS increase E1M4VT = 5T, pupil equal 5mm ODS, LR -/- motoric parese -/- BP 110/70, HR 110 RR 30
20.30 Patient GCS decrease E1M2VT = 3T, RR=32 x, BP 110/60 HR 154 --, pupil equal 5 mm ODS, LR -/- motoric parese , Informed to
Familiy (+)
23.50 Patient GCS E1M2VT= 3T RR= 35x, BP 100/50 HR 154 --, pupil equal 5 mm ODS, LR -/- motoric parese , Informed to Familiy (+)
00.30 Patient GCS decrease E1M1VT=2T, RR= 35x, BP 110/54 HR 145 --, pupil equal 5 mm ODS, LR -/- motoric parese ,
02.00 Patient GCS E1M1VT= 2T, RR=15x, BP 110/54 HR 145 --, pupil equal 5 mm ODS, LR -/- motoric parese
03.00 Patient GCS E1M1VT= 2T, RR= 24x, BP 90/54 HR 148 --, pupil equal 5 mm ODS, LR -/- motoric parese ,
04.00 Patient GCS E1M1VT= 2T, RR= 8x, BP 80/54 HR 155 --, pupil equal 5 mm ODS, LR -/- motoric parese , Informed to Familiy (+)
04.30 Patient GCS E1M1VT= 2T, Apnoe, BP 70/40 HR 165 --, pupil equal 5 mm ODS, LR -/- motoric parese , Informed to Familiy (+)
05.00 Patient GCS E1M1VT= 2T, Apnoe, BP -/-. HR 40 --, pupil equal 5 mm ODS, LR -/- motoric parese , Informed to Familiy (+), dolls eye (-)
05.10- the patient passed away.

EMG-Resusitation
Mr. H/ 29 yo/ / 40536 / Trauma
MRS: 17-11-2011
CC : Decreased consciousness
History :
4 days prior to admission, when he was a riding a motorcylce in Riung Sadang area, helmet
(-), suddenly he strucked a truck from behind and he fell down with his head hit the road.
History of unconscious (+), vomiting (+), bleeding from right and left ear (+), nose (-) and
mouth (-). He was brought to Al Islam Hospital and performed head CT Scan and chest X-ray.
Patient was treated for 4 days and because of familys wish, he was referred to Hasan Sadikin
Hospital.

Primary Survey :
A : Intubated
B : RR : 10x/mnt, symetrical shape, VBS left and right
C : P : 62x/mnt, BP : 100/70 mmHg
D : GCS : E1M2VT= 3T
Pupil : round equal 5 mm, LR -/-
Motor : paresis -/-

Secondary survey :
a.r right hemithorax : CTT (+) effective
a.r. Periorbita bilateral : hematom (+)
a.r left temporal : hematom (+)
a.r. Right and Left MAE : otorrhea (+)
a.r. Fascialis : multiple excoriated wound
Head CT Scan
Soft tissue swelling a/r left
temporoparietal
Bone discontinuity (+) left
orbital rim aspect superior,
inferior et lateral + # linear
ar left et right temporal
Salt and pepper appearance
ar left frontotemporal et
mesencephalon
Sylfian fissure is not
compressed
Sulcy and gyri are not
compressed
Ventricle and cystern are
not compressed
Midline shift (-)
Thorax X-ray 14-11-2011 : Left
pneumothorax
Thorax X-ray 14-11-2011 : Right and
left lung contusion
Laboratory :
Hb 8,9 pH 7,444
Ht 27 PCO2 31,4
Leko 14200 PO2 39,4
Trombo 57000 HCO3 21,6
Ureum 38 TCO2 22,5
Kreatinin 1,00 BE -2,5
Na 154 Saturation 74,5
K 4,7
Glucose 147
SGOT 2176
SGPT 990
WD/ Severe Head Injury (GCS 3T) + Closed
fracture left orbital rim aspect
superior, inferior et lateral + Closed #
linear ar left et right temporal + Skull
Base Fracture Right et left middle fossa
+ Cerebral contusion ar left
frontotemporal et mesencephalon + Left
pneumothorax + Right et left lung
contusion

Tx/ Conservative (NC)

BGA analysis and Thorax serial (Thorax
Surgery)
 Discussion

Coagulopathy in Trauma
Causes
Multiple factors combine to
cause acute traumatic
coagulopathy. Six factors
have been proposed as
drivers:
tissue damage/-trauma,
hypoperfusion,
hemodilution,
hypothermia,
acidosis,
inflammation

Marc Maegele,Deutsches rzteblatt International | Dtsch

Arztebl Int 2011; 108(49): 82735
Incidence
Every fourth severely
injured patient arrives at
the shock room with an
acute traumatic disorder
of the coagulation
system
Increasing incidence with
greater prehospital
volume replacement
(40% who received 2 liters
50% who received 3 liters,
70% who received 4 liters)

Marc Maegele,Deutsches rzteblatt International | Dtsch

Arztebl Int 2011; 108(49): 82735
Patophysiology

Mark J.M.Phil.Trans.R.Soc.B(2011)366,192-203
Patophysiology

Mark J.M.Phil.Trans.R.Soc.B(2011)366,192-203
Risk

The relative risk

(RR) of death is
4.6 times
higher in
patients who have
an acute traumatic
disorder of the
coagulation system

Marc Maegele,Deutsches rzteblatt International | Dtsch

Arztebl Int 2011; 108(49): 82735
Risk

Marc Maegele,Deutsches rzteblatt International | Dtsch

Arztebl Int 2011; 108(49): 82735
Recommendations

Marc Maegele,Deutsches rzteblatt International | Dtsch

Arztebl Int 2011; 108(49): 82735
Recommendations
Thank you
NP 6. Boy. Hanafi/12 yo//11061288
Consultant : Prof. Dr. dr. Kahdar W, Sp.BS (K)
MRS: 10-8-2011
CC : Decreased of consciousness
History :
2 hours prior to admission, when he was walking on the street at Soekarno
Hatta area, suddenly he hit by a motorcycle from behind, he fell down and his
head hit the road. Unconscious (+), vomiting (-), bleeding from ear (-), nose (-)
and mouth (-). He was brought to Rajawali hospital and then referred to RSHS.

Primary survey :
A : Clear with intubation + C-Spine control
B : VBS symetris, RR : 30 x/mnt
C : BP : 130/90 mmHg, HR : 100 x/m
D : GCS = E1M4VT = 5T
Pupil : Round unequal ODS : 5/3 mm, LR /+
Motor : Hemiparese Sin

Secondary survey :
a/r (R) Frontal : VE (+)
a/r (R) parietal : Laceration wound size 8x3 cm, base on depressed fracture
 Cervical x-ray :
within normal limit
Head CT-Scan (August 10th 2010)
Head CT-Scan (August 10th 2010)

Soft tissue swelling ar right

parietal
Bone discontinuity ar right
parietal
Sulci and gyri are compressed
Silvian fissure is compressed
Hyperdens mass salt and
pepper apperance ar right
parietal
Ventricle and cystern are
compressed
Midline shift (-)
Lab : Hb 11,2 13.5-17.5 Normal
Range
Ht 36 40-52
pH 7,361 7.34-7.44
Leko 31.100 4400-11300
PCO2 29,1 35-45
Trombo 532200 150.000-
450.000 PO2 91,4 69-116

Ureum 14 15-50 HCO3 16,2 22-26

Kreatinin 0,50 0.7-1,2 TCO2 17,1 22-29

BE -7,8 -2-+3
Blood 277 <140
glucosa Saturation 92,8 95-98

Na 138 135-145

K 3,4 3,6-5,5

WD/ Severe HI (5T) + open depressed fracture > 1 table at

Right parietal
Th/ Local debridement

NCCU
 ER-2 . Boy. Dede Ridwan / / 7 yo / 29591/ Trauma
MRS:26-8-2011
CC: Decreased consciousness
History:
12 hour prior to admission, when he was playing in front of his house at
Antapani area, suddenly he was strucked by a motorcycle with high speed
from left side, he fell down with his head hit the ground. History of
unconscious (+), vomiting (-), bleeding from ENM (-). He was brought to
Medika Antapani hospital and referred to Santo Yusuf hospital then
perform a CT-Scan, because of financial problem he was referred to RSHS.

Primary Survey:
A : Clear with intubation+ C-Spine control
B : RR : 35 x/mnt, , symetrical shape and movement, VBS right=left
C : BP : 130/70 mmHg, HR : 145 x/mnt, reguler
D : GCS E1M1VT = 2T
Pupil : round, unequal ODS 5/3 mm, LR /+
motoric : no parese

Secondary Survey :
a.r. frontal region : Hematome (+)
a.r bilateral periorbita : Hematome (+)
Skull X-Ray : no fracture line
CT-Scan
CT-Scan
CT-Scan

Soft tissue swelling (+) at

bifrontal
Bone discontinuity (+) at right
frontal
Sulcus and gyrus are compressed
Ventricle and cictern are
compressed
Sylvian fissure is compressed
Hiperdens mass (+) at right
frontal and intaventricular system
Periventriculer edema (+)
Midline shift (+) > 5mm to the
left
Lab Hb 10,1 13.5-
17.5 pH 7,466 7.34-7.44
PCO2 28,8 35-45
HMT 30 40-52
Leko 11.800 4400- PO2 186,4 69-116
11300 HCO3 20 22-26
Trombo 620.000 150.000- TCO2 20,8 22-29
450.000
BE -3,7 -2-+3
Ureum 26 15-50
Saturati 99 95-98
Kreatinin 0,45 0.7-1,2 on
Blood 133 <140 PT 13,4 9,8-13,8
glucosa
aPTT 35,4 15,8-35,8
Na 139 135-145
K 3,6 3,6-5,5

WD/ Severe Head Injury (GCS=2T) + ICH at

right frontal + IVH + SAB

Th/ Closed observation (NC)

Forced discharged