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Despite advances in emergency medical systems (EMS) and trauma care, deaths from injury have increased in the United States over the last decade.1 In both the civilian2 and military3 settings, uncontrolled hemorrhage is the leading cause of preventable death after injury. In civilian studies, >95% of deaths from hemorrhage occur within the first 24 hours at a median time <3 hours.2 Consequently, there is intense interest worldwide in the pathogenesis of trauma induced coagulopathy (TIC), and its early management. While there have been substantial insights, the words of Mario Stefanini in his address to the New York Academy of Medicine in 19544 remain applicable today:
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“The ponderous literature on the subject of hemostasis could perhaps be considered a classical example of the infinite ability of the human mind for abstract speculation. For several years, the number of working theories of the hemostatic mechanism greatly exceeded and not always respected the confirmed experimental facts. In recent years, however, the revived interest in this field has led to an accumulation of new findings which has been almost too rapid for their orderly incorporation into a logical working pattern. As a result, we have rapidly gone from a state of orderly ignorance to one of confused enlightenment”
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Although transfusion medicine has undergone enormous development over the past 60 years since the challenge issued by Stefanini, important gaps in scientific knowledge persist, and several fundamental issues involving the diagnosis and management of TIC remain controversial. The more we learn about TIC the more we appreciate the contributions of surgical scientists from the past century who had the insight to form the basis of our current understanding of trauma-related bleeding. This chapter will refresh important historical landmarks in our evolution of understanding TIC, synthesize recent investigations into the pathophysiology underlying these processes, and provide a rationale for current diagnostic and resuscitation strategies in these patients.
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HISTORICAL PERSPECTIVE
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The evolution of our understanding of the complexities of trauma induced coagulopathy has been, in large part, the result of collaboration between civilian and military teams. The early reports of TIC were generated from military research teams, often including civilian consultants, during major wars. These novel observations would then intensify hemostasis research in civilian centers. Ultimately, the resulting findings improved coagulopathy management in subsequent conflicts, and primed the environment for making new observations. The specific contributions to our understanding of TIC, however, are somewhat difficult to ascertain from World War I through Vietnam because the primary focus was on optimizing shock resuscitation at a time when plasma or whole blood was employed to replace acute blood loss.5 Nonetheless, several landmark contributions are well recognized.
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In 1916 the US National Research Council formed a subcommittee on traumatic shock that collaborated with the British Medical Research Committee to study wounded soldiers in the front lines of France. Among them was Walton ...