Mechanisms of early trauma-induced coagulopathy: The clot thickens or not?

Traumatic-induced coagulopathy (TIC) is a hemostatic disorder that is associated with significant bleeding, transfusion requirements, morbidity and mortality. A disorder similar or analogous to TIC was reported around 70 years ago in patients with shock, hemorrhage, burns, cardiac arrest or undergoing major surgery, and the condition was referred to as a severe bleeding tendency, defibrination syndrome, consumptive disorder, and later by surgeons treating US Vietnam combat casualties as a diffuse oozing coagulopathy. In 1982, Moore's group termed it the bloody vicious cycle, others the lethal triad, and in 2003 Brohi and colleagues introduced acute traumatic coagulopathy (ATC). Since that time, early TIC has been cloaked in many names and acronyms, including a fibrinolytic form of disseminated intravascular coagulopathy (DIC). A global consensus on naming is urgently required to avoid confusion. In our view, TIC is a dynamic entity that evolves over time and no single hypothesis adequately explains the different manifestations of the coagulopathy. However, early TIC is not DIC because an increased thrombin-generating potential in vitro does not imply a clinically relevant thrombotic state in vivo as early TIC is characterized by excessive bleeding, not thrombosis. DIC with its diffuse anatomopathologic fibrin deposition appears to be a latter phase progression of TIC associated with unchecked inflammation and multiple organ dysfunction.