Trauma patients face shifting coagulation risks in ICU

Severe polytrauma and hemorrhage represent a common and life-threatening condition that frequently results in intensive care unit admission for survivors of initial injury. A recent review published in Annals of Intensive Care examines the complex hemostatic derangements that occur in these critically injured patients. The study, authored by Christopher R. Reed, Nicola Curry, Nicole P. Juffermans, and Matthew D. Neal, examines derangements collectively referred to as trauma-induced coagulopathy. This condition arises from the injury itself, hypoperfusion caused by hemorrhagic shock, and the resuscitative efforts undertaken to stabilize the patient. The review highlights that while the trauma population is notoriously heterogeneous, the coagulopathy generally follows a distinct temporal pattern. It can generally be divided into an early hypocoagulable phase and then a late hypercoagulable, prothrombotic phase.

Existing literature on trauma-induced coagulopathy has historically focused heavily on reversing and preventing hypocoagulation during the early, acute phase of injury. However, intensivists commonly manage patients throughout the later post-acute resuscitation phase, a period during which thrombotic complications are common. These complications can lead to major morbidity and mortality, presenting a significant clinical challenge. The review emphasizes that deep venous thrombosis and other macrovascular thrombotic events occur frequently after trauma. Managing these patients requires a delicate balance, as thrombosis prophylaxis and treatment present a challenge for individuals who remain at high risk for bleeding simultaneously.

The prothrombotic phenotype in late trauma-induced coagulopathy is driven by several underlying biological contributors. Derangements in platelet activation play a key role, as do instances of endothelial dysfunction. Additionally, the suppression of fibrinolysis contributes to this prothrombotic phenotype. The review also points to crosstalk between the innate immune system and the coagulation systems as a significant factor. Emerging roles for specific molecular players, such as high mobility group box 1, extracellular vesicles, and endogenous inhibitors, are described as part of this complex pathophysiology.

An in-depth understanding of risk factors specific to trauma patients is essential for optimizing clinical management. This includes recognizing iatrogenic contributions from resuscitation and hemostatic efforts during the pre-intensive care phase. By stratifying thromboembolic risk based on these specific factors, clinicians can better optimize prophylaxis and surveillance efforts. The review stresses the importance of an individualized approach to the assessment of hemorrhagic and thrombotic risks for each patient.

The article discusses general approaches to thromboprophylaxis, monitoring, and anticoagulation in this specific patient population. It summarizes relevant risk stratification systems and guidelines used for the clinical management of thromboembolic risk among trauma patients. However, the review also highlights limitations in these existing systems and guidelines. These limitations are highlighted as areas for future research.

There is a rapidly accruing body of evidence examining the foundations of hemostatic dysfunction in the intensive care unit after traumatic injury. Patients in this setting remain at high risk for both thromboembolic and bleeding complications simultaneously. Additionally, they face the risk of thrombosis-mediated organ dysfunction. While exciting novel strategies aiming to treat this dysfunction are currently in the preclinical testing phase, the review emphasizes that early and aggressive guideline-driven thromboprophylaxis is paramount. This approach is paramount to minimizing morbidity associated with late trauma-induced coagulopathy.

Intensivists must be facile with thrombotic risk factors and prevention strategies in this patient population to provide optimum care. The review serves as a comprehensive summary of the challenges and strategies involved in caring for the critically injured patient.

Subject of Research: Hemostatic abnormalities and thromboprophylaxis in trauma-induced coagulopathy

Article Title: Hemostatic abnormalities after trauma resuscitation: challenges and strategies in caring for the critically injured patient

Article References: Reed, C. R., Curry, N., Juffermans, N. P., & Neal, M. D. (2025). Hemostatic abnormalities after trauma resuscitation: challenges and strategies in caring for the critically injured patient. Annals of Intensive Care, 15(1), Article 163. https://doi.org/10.1186/s13613-025-01587-0

Image Credits: AI Generated

DOI: 10.1186/s13613-025-01587-0

Keywords: trauma-induced coagulopathy, hemostasis, thrombosis, intensive care, polytrauma, resuscitation, bleeding risk, clotting, clinical management, risk stratification, Hemostatic, abnormalities