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Treatment of Life-Threatening Hemorrhage Following Blunt Trauma: The Role of Recombinant Factor VIIa

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Treatment of Life-Threatening Hemorrhage Following Blunt Trauma: The Role of Recombinant Factor VIIa

Tuesday, March 22nd, 2005
Author: SABM Staff

Treatment of Life-Threatening Hemorrhage Following Blunt Trauma: The Role of Recombinant Factor VIIa

Exsanguinations have been reported to be the second most frequent cause of death in trauma patients after nervous system injuries (Sauaia A et al., J Trauma 1995;38:185-93). They account for almost half of all trauma deaths. Prehospital treatment of hemorrhagic shock is limited and based on stopping a compressible bleeding by direct external pressure, closure of wounds and reduction and/or splinting of fractures, Dr. Geeraedts and colleagues note in the April issue of Injury (Geeraedts LM Jr et al., Injury 2005;36:495-500). Volume resuscitation with crystalloids, colloids and/or transfusion of blood products to preserve acceptable vital signs is started on scene, followed by rapid transport to the hospital. In-hospital treatment is based on controlling hemorrhage by performing “damage control� surgery and ongoing resuscitation by massive transfusion of blood products.

In patients with blunt trauma, surgical measures to control the bleeding may be difficult to perform because of the presence of diffuse bleeding. In addition, due to persistent bleeding, hypothermia and metabolic acidosis, a profound coagulopathy can occur, which will aggravate the bleeding and may be life-threatening. Anecdotal evidence as well as a yet unpublished randomized controlled trial suggest that treatment with recombinant factor VIIa (rFVIIa) might be beneficial in trauma subjects with persistent life-threatening hemorrhage. However, most case series have reported on patients with penetrating wounds. In a retrospective case review, Dr. Geeraedts and colleagues analyze data on patients with blunt traumatic injury who were treated with rFVIIa at the University Medical Centre Nijmegen and the Rijnstate Hospital Arnhem, The Netherlands, between 2001 and 2003.

Eight trauma patients, the authors report, were treated with rFVIIa due to uncontrolled bleeding over the three-year period. All patients had been admitted to one of the two trauma centers with blunt trauma resulting in bleeding from abdominal and/or thoracic injuries and/or bone fractures. On admission, most patients were hypothermic and had metabolic acidosis, and five patients were hypotensive. All patients underwent at least one surgical or radiological (embolization) procedure before administration of rFVIIa. rFVIIa was administered between 9 and 38 hours after trauma in doses varying from 55 to 90 μg/kg. In one patient, a second dose was administered 14 hours after the first dose because of an increase in chest drain production after an initial decrease. When compared to the phase before rFVIIa administration, after treatment the need for transfusion of red blood cells decreased from 31.3 ± 15.8 to 6.1 ± 6.8 units (p = 0.003), fresh frozen plasma from 13.3 ± 6.6 to 5 ± 6.3 units (p = 0.02), and platelets from 3.6 ± 1.8 to 1.5 ± 2.3 units (p = 0.01). In all patients the critical bleeding stopped. Three patients died of non-hemorrhagic complications.

In the reported cases, the authors point out, the dose of rFVIIa and the timing of administration were not based on a standard protocol but left to the discretion of individual physicians. rFVIIa was administered when no other options for treatment, either surgical or medical, were left and bleeding would have been lethal. The need for administration of blood products was significantly reduced after treatment with rFVIIa. The authors comment that administration of rFVIIa seems to be beneficial in blunt trauma patients with uncontrolled bleeding, but the optimal timing and dose of administration remain to be established. “Prospective randomized trials with emphasis on safety, survival rates and transfusion consumption are needed to elucidate the role of rFVIIa as an adjunct to bleeding control in blunt trauma,� they conclude.

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Mr. Jan B. Wade
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