After a massive transfusion and trauma, the clotting cascade is altered both intrinsically and extrinsically by alterations of thrombomodulin-protein C which increases coagulation activation and impairment, and increased fibrinolysis (Vernon, Morgan & Morrison, 2019). The alterations in pathways from massive transfusion is due to dilution and thrombocytopenia from the blood products and their preservatives themselves (Vernon, Morgan & Morrison, 2019). This process is jump-started due to the massively increased fibrinolysis from plasminogen binding to fibrin, then tPA activates and turns plasminogen into plasmin, as a systemic result of dilution and thrombocytopenia after blood product administration (Vernon, Morgan & Morrison, 2019).
Some specific assessment findings on a patient would be blood oozing or hemorrhage from any insertion site that was previously performed, which indicates that there is fibrinolysis occurring (Latif et al., 2016). This would prompt an emergent lab work for a PT and PTT as well as fibrinogen levels, fibrinogen degradation products, platelet count, hemoglobin and hematocrit, and peripheral smear looking for schistocytes or fragmented erythrocytes (Latif et al., 2016). In DIC, a Pt and PTT would be increased, fibrinogen decreased, thrombocytopenia and low hematocrit, and presence of schistocytes or fragmented erythrocytes indicating mechanical shearing from a possible clot (Latif et al., 2016). These positive findings would indicate a higher ISTH score which is indicative of DIC (Hayakawa, 2020).
In this scenario, it is most likely that the patient is in the Bleeding Phase of DIC and has essentially skipped the clotting phase of DIC (Hayakawa, 2020). There is a two-part process in the management of this scenario, first how much is the patient bleeding or oozing from the site, second what are the lab values of platelets in conjunction with the bleeding or not bleeding values (Hayakawa, 2020). For example, If the patient is actively bleeding then a transfusion of platelets would be indicated when the platelets drop below 50, and if they are not bleeding then when the platelets drop below 20 (Hayakawa, 2020). There is the option to use cryoprecipitate but it is reserved for those who are bleeding (Hayakawa, 2020).
For this patient in particular, since DIC is a dynamic disease of massive coagulation and fibrinolysis, we have to be aware of the patient’s ability to clot pre and post-transfusion (Hayakawa, 2020). It is possible to send the patient into a hypercoagulable state with too much administration of clotting factors (Hayakawa, 2020). It is important to go “low and slow” as in ordering one unit of replacement at a time of FFP or Platelets and rechecking the labs post-transfusion, reassessing, then deciding if another dose is required (Hayakawa, 2020).
References:
Hayakawa, M. (2020). Management of disseminated intravascular coagulation: current insights on antithrombin and thrombomodulin treatments. Open Access Emergency Medicine, 1, 25. https://doi-org.lopes.idm.oclc.org/10.2147/OAEM.S135909
Latif, E., Adam, S., Rungruang, B., Al-Hendy, A., Diamond, M. P., Rotem, E., Cannell, J., & Browne, P. C. (2016). Use of uterine artery embolization to prevent peripartum hemorrhage of placental abruption with fetal demise & severe DIC. Journal of Neonatal-Perinatal Medicine, 9(3), 325–331. https://doi-org.lopes.idm.oclc.org/10.3233/NPM-16915108
Vernon, T., Morgan, M., & Morrison, C. (2019). Bad blood: A coagulopathy associated with trauma and massive transfusion review. Acute medicine & surgery, 6(3), 215–222. https://doi.org/10.1002/ams2.402