Consumptive coagulopathy from massive transfusion: Clinical sciences

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Introduction 0:00–1:42

Massive transfusion refers to the rapid administration of blood products to patients suffering from life threatening hemorrhagic shock or severe coagulopathy caused by trauma, major high risk operations, obstetric complications, or disseminated intravascular coagulopathy or DIC.
Massive transfusion protocol, or MTP for short, is a systematic approach in providing a balance of blood products, such as packed red blood cells or PRBC, fresh frozen plasma or FFP, and platelets in a 1 to 1 to 1 ratio.
Remember, platelets and fibrinogen play an important role in primary hemostasis by forming a platelet plug. Then, the clotting factors through the coagulation cascade help to form a blood clot to stop the bleeding.
In the setting of massive hemorrhage, the body consumes as much of these factors as it can in an attempt to stop the bleeding.
Without proper replacement, coagulopathy can worsen and become fatal very quickly. So, it’s very important to determine which factors are deficient so that proper balance of blood products can be given.
Balanced transfusion decreases the risk of serious transfusion-related complications, such as consumptive coagulopathy; this occurs when one type of blood product is given in excess, causing dilution and consumptive depletion of platelets and clotting factors, and ultimately leading to worsening coagulopathy and bleeding.
Now, when a patient presents with chief concerns suggestive of consumptive coagulopathy from massive transfusion, the first step is to perform a focused history and physical.

Focused H&P 1:42–2:50

Keep in mind that patients who are unstable, intubated, or have altered mental status might not be able to provide history.
So, make sure to check their medical chart to determine the injury, estimated loss of blood, as well as the type and amount of blood products transfused.
Typically, the history will include a recent massive transfusion, which may have been given following trauma, high-risk surgery like cardiac or aortic procedures, massive hemorrhage, or DIC.
On physical exam, you might notice altered mental status, hypotension, fever, tachycardia, and dyspnea. These are signs of shock!
Additionally, you might see jaundice, petechiae, purpura, or ecchymoses, as well as hematuria or hemoptysis, all signs of coagulopathy.
With these clinical features, you should suspect consumptive coagulopathy from a massive transfusion right away. Alright, once you suspect coagulopathy from massive transfusion, your next step is to order labs like CBC, PT/INR, aPTT, fibrinogen, and D-Dimer, as well as a peripheral blood smear to determine the type of coagulopathy.

Diagnostic evaluation 2:50–5:10

CBC provides information on red blood cells through hemoglobin and hematocrit, in addition to serum platelet levels. On the other hand, PT/INR and aPTT give us information about the clotting factors and their efficacy.
For example, elevated PT/INR and aPTT means that the body is taking longer to form clots, which can happen when there’s a deficiency of the clotting factors.
Next, fibrinogen and D-Dimer give us information on the patient’s thrombolytic pathway. Fibrinogen is a protein that converts into fibrin to form a mesh-like structure to stabilize the blood clot.
So, decreased fibrinogen level means that the body might not be able to stabilize the clots and temporize the bleeding. Conversely, D-dimer is a product of clot degradation.
Remember that clot degradation, or fibrinolysis,occurs as soon as the clot is formed. This prevents the clots from becoming too large.
An elevated D-dimer indicates excessive fibrinolysis, which can occur when the body forms increased amounts of blood clots.
Keep in mind, D-dimer is not specific to certain types of coagulopathies, and can be elevated in a wide array of medical conditions like deep vein thrombosis and pulmonary embolism.
Finally, peripheral blood smear provides morphologic information about the blood cells and serum fragments which can help us narrow down our differentials.
Here’s a clinical pearl! Coagulopathy in the setting of acidosis and hypothermia is known as the lethal triad.
These three conditions can all result from hemorrhagic shock, and can propagate each other, resulting in a vicious cycle of worsening coagulopathy and multiorgan failure, which can quickly become fatal.
To break this vicious cycle, all three of these factors must be addressed and treated. Now let’s dive in and discuss each type of coagulopathy, starting with coagulation factor deficiency.

Coagulation factor deficiency 5:10–6:30

Labs typically reveal PT/INR and aPTT are elevated, while hemoglobin, hematocrit, platelet count, serum fibrinogen, and D-Dimer can be normal.
On peripheral blood smear, no schistocytes will be present. If these are your findings, you can make your diagnosis.
To treat, start an infusion of recombinant factor concentrate; if factor concentrate is not available, you can give fresh frozen plasma or FFP, or prothrombin complex concentrate or PCC.
In addition, be sure to provide supportive care to reduce the risk of the lethal triad. Here’s a clinical pearl!
Recombinant factor concentrate contains artificially produced clotting factors initially made to treat hemophilia clotting disorders.
FFP is the plasma component of the human blood that’s rich in clotting factors. PCC also contains clotting factors, including proteins C and S.
Thus, PCC can also be used to reverse effects of anticoagulation medications like warfarin. (end for March 23) Alright, next we have platelet deficiency.

Platelet deficiency 6:30–7:01

On labs, you can expect to find thrombocytopenia and fibrinogen levels that are decreased. Other labs like hemoglobin, hematocrit, PT/INR, aPTT, and D-Dimer levels can be normal, and peripheral blood smear won’t have schistocytes.
These findings are characteristic of platelet deficiency, which can be treated with platelet infusion in addition to supportive care.
Now let’s move on to disseminated intravascular coagulation or DIC. Patients with DIC tend to have normal hemoglobin and hematocrit.

DIC 7:01–7:51

However, they will have thrombocytopenia and decreased serum fibrinogen levels. They also likely will have elevated PT/INR, aPTT, and serum D-Dimer.
In addition, schistocytes will be seen on peripheral blood smear. With these results, diagnose DIC and treat immediately with platelet infusion, FFP, and cryoprecipitate.
Patients also could benefit from antithrombin III concentrate administration. Last but not least, don’t forget supportive care.
Finally, let’s turn to anemia. Labs here will reveal decreased hemoglobin and hematocrit, but normal platelet count, PT/INR, aPTT, serum fibrinogen, and D-Dimer.

Anemia 7:51–8:31

Also, no schistocytes will be seen on their peripheral smear. These findings indicate that your patient has anemia.
These patients often have a source of external bleeding that may require hemostatic agents, such as a hemostatic gauze. They would also benefit from a balanced transfusion of packed red blood cells, platelets, and FFP to avoid diluting any clotting components.
And once again, provide supportive care. Alright, as a quick recap… Consumptive coagulopathy from massive transfusion results from unbalanced loss of a single blood component.

Review 8:31–9:20

The major blood components involved are red blood cells, platelets, clotting factors, and fibrinogen. Findings on a focused history and physical exam help to confirm the presence of some type of coagulopathy, such as coagulation factor deficiency, platelet deficiency, DIC, or anemia.
The specific coagulopathy is then identified using laboratory tests, including CBC, PT/INR, aPTT, fibrinogen, and D-Dimer, as well as a peripheral blood smear.
Based on the blood component that’s primarily deficient, the treatment is aimed toward correcting the deficiency in