Coagulopathy - NYSORA

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Learning objectives

  • Definition of coagulopathy
  • Management of coagulopathy

Definition and mechanisms

  • Coagulopathy is a condition in which the blood’s ability to coagulate (form clots) is impaired
  • Leading to a tendency toward prolonged or excessive bleeding and occurring spontaneously or following an injury 
  • Caused by:
  • Activation of coagulation will lead to consumption of clotting factors, particularly factor V and fibrinogen, leading to a consumptive coagulopathy

Signs and symptoms

  • Easy bruising
  • Hemarthrosis (bleeding into a joint cavity)
  • Hemorrhage after childbirth
  • Accumulation of blood in the pleural cavity (hemothorax)
  • Very heavy menstrual flow
  • Loss of blood through the nose
  • Anal bleeding
  • Livedo reticularis
  • Thrombocytopenia
  • Gingival bleeding
  • Rheumatisms
  • Bloody gums
  • Joint pain and swelling
  • Blood in the urine
  • Double vision
  • Severe head or neck pain
  • Repeated vomiting
  • Difficulty walking
  • Convulsions or seizures


  • Obtain a blood sample for a full coagulation screen
  • Perform near-patient testing such as ROTEM or TEG
  • Consider permissive hypotension in patients with moderate bleeding
  • Perform massive volume resuscitation in a patient with severe hypovolemic shock
  • Limit crystalloid and colloid infusions as this leads to acidosis, hypothermia and coagulopathy
  • Transfuse red blood cells → hemoglobin target is between 7-9 dL/L
  • Administer fresh frozen plasma, platelets, cryoprecipitate, and concentrated red cells, depending on clotting results and blood loss
  • Correct hyperfibrinolysis with tranexamic acid (see also blood transfusion)
  • Avoid volatile anesthetics as they lead to vasodilation
  • Administer multimodal analgesia (opioids, NMDA glutamate receptor antagonists)
  • Regional anesthesia is not indicated as it takes too much time and could mask compartment syndrome
  • Avoid hypothermia as this worsens coagulopathy 
    • With passive rewarming, active external rewarming, and active internal rewarming
    • Hypothermia impairs thrombin generation
    • Hypothermia contributes to platelet dysfunction
  • Consider complications associated with plasma administration such as TRALI, sepsis, and ABO incompatibility

Trauma-induced coagulopathy

hyperfibrinolysis, fibrin deficit, thrombin generation deficit, platelet deficit, clot deficiency, TXA, cryoprecipitate, FFP, PCC, platelet concentrate, heparin, ROTEM

TXA, tranexamic acid; PCC, Prothrombin Complex Concentrates

Suggested reading

  • Hofer S, Schlimp CJ, Casu S, Grouzi E. Management of Coagulopathy in Bleeding Patients. J Clin Med. 2021;11(1):1.
  • Pollard BJ, Kitchen, G. Handbook of Clinical Anaesthesia. Fourth Edition. CRC Press. 2018. 978-1-4987-6289-2.
  • Simmons J, Powel M. 2016. Acute traumatic coagulopathy: pathophysiology and resuscitation. BJA: British journal of anaesthesia. 17;3:31-43.
  • Gaunt, C., Woolley, T., 2014. Management of haemorrhage in major trauma. Continuing Education in Anaesthesia Critical Care & Pain 14, 251–255.
  • Daniel Bolliger, Klaus Görlinger, Kenichi A. Tanaka, David S. Warner; Pathophysiology and Treatment of Coagulopathy in Massive Hemorrhage and Hemodilution. Anesthesiology 2010; 113:1205–1219.

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