The traditional drug for anticoagulation in those with a high risk of thrombosis is a vitamin K antagonist, such as warfarin. On the other hand, this drug has several limitations and hemorrhagic complications. Recently, novel or non-vitamin K-dependent antagonist oral anticoagulants (NOACs) have been developed to solve these problems. This paper presents a case of adaptation of NOAC for a warfarin anticoagulated patient with traumatic ongoing hemorrhages with a discussion of the clinical implications of NOAC.

The mortality of patients with hemodynamic instability due to severe pelvic fracture is high despite multidisciplinary management. Current management algorithms for these patients emphasize pelvic angioembolization (AE) for hemorrhage control. However, a surgical procedure is often needed because AE is time-consuming and approximately only 15% of patients have arterial bleeding. Most hemorrhages from severe pelvic fracture originate from venous or bone injury. Current research demonstrates the effectiveness of preperitoneal pelvic packing (PPP) in hemorrhage control. However, there are no reports of its use in Korea. Accordingly, we present our early experiences of PPP for control of hemorrhage due to severe pelvic fracture in a trauma center in Korea.

Citations

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• Improvement of outcomes in patients with pelvic fractures and hemodynamic instability after the establishment of a Korean regional trauma center
  Ji Young Jang, Hongjin Shim, Hye Youn Kwon, Hoejeong Chung, Pil Young Jung, Seongyup Kim, Hoon Ryu, Keum Seok Bae
  European Journal of Trauma and Emergency Surgery.2019; 45(1): 107.     CrossRef

Traumatic carotid-cavernous fistula (TCCF) is a pathologic communication between the internal carotid artery and cavernous sinus, and is associated with craniomaxillofacial trauma. TCCF are very rare, occurring in 0.17∼0.27% of craniomaxillofacial trauma cases. We describe a 76-year-old woman treated for multiple fractures including the skull base, left temporal bone, right tibia and fibula, left clavicle, and fifth and seventh rib fractures. She developed symptoms of TCCF two weeks after the initial trauma. We successfully treated her by endovascular occlusion of the internal carotid artery.

Traumatic bleeding is a prime cause of mortality after trauma, responsible for 40% of trauma- related early death. Traumatic bleeding often occurs as direct bleeding from injured site and is frequently complicated by trauma-induced coagulopathy (TIC). Traditionally, TIC was related to hemodilution, coagulation factor consumption, acidosis and hypothermia. However, TIC is now considered shock-associated hypoperfusion, a combination that activates the protein C pathway. While this adds to the understanding of this condition, the pathophysiology of TIC is not fully understood. Because TIC is composed of multiple factors, point-of-care testing (POCT) of coagulopathy that can rapidly provide information on an individual patient’s coagulation status is important. Among POCT tests are viscoelastic tests (VET), of which the most commonly used are thromboelastography and thromboelastometry. These provide rapid and dynamic bedside assessment of TIC. Treatment algorithms using VET results reduce mortality, morbidity and amount of transfusion. Although VET offers several advantages, there are limitations. VET cannot reduce mortality and morbidity, cannot fully assess the entire coagulation process, need ongoing quality control protocols, and require trained personnel. In conclusion, despite its limitations, VET has many advantages in assessment of TIC, POCT and treatment of TIC. Efforts to overcome the limitations are needed.