From
StayCurrentMD
Coagulopathy and Analgesia
With Dr. Adam Vogel · hosted by Dr. Alexander Gibbons
Part of
Neuroblastoma 26 items
Chapter 1 of 10 · Case-Based Learning
Trauma case intro
Introduction and Case Presentation: Trauma with Coagulopathy
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Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
In coagulopathic trauma patients, trending coagulation values over time is more clinically useful than a single point measurement.
Initial assessment of coagulopathy should include review of crystalloid volume, blood product volumes, and transfusion ratios (red cells to plasma to platelets) received during resuscitation.
Goal-directed hemostatic therapy requires INR, PTT, hemoglobin, platelet count, and ideally viscoelastic monitoring (TEG or ROTEM) to assess functional coagulation.
Viscoelastic monitoring (TEG/ROTEM) provides global assessment of the entire coagulation system including hemostasis and fibrinolysis by transducing mechanical changes in clotting blood into electrical signals.
Viscoelastic tests measure four phases: time to clot formation (factor function), amplification rate (fibrinogen function), clot strength (platelet function), and fibrinolysis.
Prolonged clot formation time on viscoelastic monitoring indicates factor deficiency and should be treated with plasma.
Abnormal amplification phase (alpha angle) on viscoelastic monitoring indicates fibrinogen dysfunction and should be treated with cryoprecipitate or fibrinogen concentrate.
Reduced clot strength (maximal amplitude on TEG) indicates platelet dysfunction and can be treated with platelet transfusion or DDAVP in specific populations like end-stage renal disease patients.
Rapid drop-off in clot strength on viscoelastic monitoring indicates hyperfibrinolysis and may warrant antifibrinolytic therapy with tranexamic acid or aminocaproic acid.
Tranexamic acid has been widely used in adults for trauma-associated hyperfibrinolysis and is being used increasingly in children.
Viscoelastic monitoring results are available within 5-15 minutes, compared to 30-45 minutes for conventional coagulation tests (PT/INR/PTT).
Severely injured children exhibit two fibrinolytic phenotypes: hyperfibrinolysis (rapid fibrinolysis contributing to coagulopathy) and fibrinolytic shutdown (smaller percentage).
Tranexamic acid may be beneficial in hyperfibrinolytic patients but potentially detrimental in fibrinolytic shutdown patients by increasing hypercoagulability.
In adults, balanced resuscitation with 1:1:1 ratio of red cells to plasma to platelets improves mortality based on prospective observational studies and randomized trials.
Balanced resuscitation in adults improves multiple ICU outcomes including kidney injury, ventilator duration, ICU length of stay, and infection rates.
Balanced resuscitation achieves coagulopathy control more efficiently with less overall blood product volume despite appearing to use more products.
In pediatric trauma, retrospective studies using National Trauma Databank and TQIP show that 1:1 ratio of red cells to plasma provides improved outcomes.
The ATOMIC Group published a study of over 100 severely injured pediatric trauma patients showing best outcomes and survival with resuscitation closer to 1:1:1 balanced ratio.
Standard of care for hemostatic resuscitation in 2019 is balanced resuscitation with 1:1:1 ratio of red cells, plasma, and platelets.
Massive transfusion protocols should deliver blood products in 1:1:1 ratio, and this is part of American College of Surgeons Committee on Trauma verification standards for trauma centers.
Multimodal approach to postoperative analgesia has substantial benefits and should include narcotics, non-narcotics, regional techniques, and non-pharmacologic interventions.
Partnering with anesthesia pain service teams and pharmacists is valuable for managing complex postoperative pain in pediatric patients.
Non-steroidal anti-inflammatory medications (IV Toradol or oral NSAIDs) help minimize narcotic use and can decrease postoperative complications like ileus.
Regional analgesia techniques including epidural catheters and ultrasound-guided nerve blocks are effective for managing incisional pain and reducing intraoperative and postoperative opioid use.
Indwelling analgesic catheters that deliver slow-release local anesthetics into surgical wounds have been shown to be helpful for large incisions.
Gabapentinoids (pregabalin and gabapentin) are useful components of multimodal pain management.
Non-pharmacologic therapies for pain and distress include creating child-friendly environments, supporting families, pet therapy, and augmented virtual reality devices for procedures like dressing changes in burn patients.
When children are less stressed, their pain tends to be more manageable.
Most intubated postoperative patients receive combination sedative therapy with benzodiazepines (midazolam or lorazepam) plus low-dose narcotic infusions (fentanyl, morphine, or dilaudid).
Dexmedetomidine (Precedex) is used increasingly for sedation, particularly in congenital heart/cardiac populations, and is helpful for decreasing anxiety associated with intubation.
Validated pain assessment tools exist across all pediatric ages including FLACC (Faces, Legs, Activity, Cry, Consolability) for preverbal children, validated in surgery, trauma, cancer, and other disease processes.
Other validated pediatric pain scales include Faces Pain Scale Revised, Visual Analog Scale (VAS), Color Analog Scale (CAS), and Non-Communicating Children's Pain Checklist (with postoperative version).
Visual Analog Scale and Color Analog Scale tend to be better received than Faces Pain Scale in pediatric patients.
Richmond Agitation Sedation Score (RASS) is the most commonly employed sedation assessment technique in adults.
State Behavioral Score (SBS) is a commonly used sedation assessment score in pediatric ICU patients.
Goal-directed sedation aims to keep patients comfortable but not comatose and not overly agitated, allowing them to wake up, interact, and be assessed.
The Society of Critical Care Medicine's ABCDEF bundle is an evidence-based approach for ICU management, extensively studied in adults and increasingly used in pediatric ICUs over the past five years.
The ABCDEF bundle components are: A (assess and manage pain), B (spontaneous awakening and breathing trials), C (choice of analgesia and sedation), D (delirium assessment, prevention, management), E (early mobility and exercise), F (family engagement).
Daily spontaneous awakening trials (sedation holidays) and spontaneous breathing trials in appropriate patients decrease duration of sedation, mechanical ventilation, and ICU stay, improving overall outcomes in both adults and children.
Most ICUs have escalation and de-escalation sedation protocols developed with hospital pharmacists, often unique to the ages and patient populations of that institution.
Minimizing benzodiazepine use is important because benzodiazepines contribute to development of delirium.
Benzodiazepine-sparing agents like dexmedetomidine (Precedex) are important for reducing delirium risk.
Approximately 40% of pediatric ICU patients will experience delirium at some point during their ICU stay, with incidence increasing the longer children remain in the ICU.
Delirium is a waxing and waning change in mental status.
Risk factors for pediatric delirium include age less than 2 years, mechanical ventilation, benzodiazepine use, narcotic use, and physical restraints.
Validated delirium assessment tools include CAM-ICU (Confusion Assessment Method for ICU), pediatric CAM-ICU, preschool CAM-ICU (developed at Vanderbilt), and CAP-D (Cornell Assessment of Pediatric Delirium).
Delirium assessment requires first assessing sedation level; comatose patients cannot be reliably assessed for delirium using screening tools.
Delirium screening tools assess components including appropriate eye contact, purposeful actions, awareness of surroundings, ability to interact with family/caregivers, and ability to communicate.
Positive delirium screening does not definitively diagnose delirium; patients may be uncomfortable from uncontrolled pain, worsening illness, sepsis, or ventilator dyssynchrony requiring detailed clinical assessment.
Non-pharmacologic delirium management includes environmental modifications: maintaining sleep-wake cycles with lights-on during day and lights-off at night, family presence, child life services, and pet therapy.
Melatonin can be effective for managing sleep difficulties in ICU patients as part of delirium management.
Atypical antipsychotics, particularly risperidone started at low dose and titrated up, can be helpful in managing delirium.
Delirium prevention requires addressing underlying medical needs (infection control, early cultures/antibiotics when indicated), family involvement, and maintaining normal sleep-wake cycles and routines as much as possible.
Dr. Vogel completed fellowships in both pediatric surgery and surgical critical care, with research interests in viscoelastic monitoring, goal-directed hemostatic resuscitation, massive transfusion, and optimizing anticoagulation/ventilation during ECLS.