A patient presents found in the rural backcountry after a motor vehicle accident. She has a grade V liver laceration and is not stable for transfer. Your general surgeon is getting ready to take her to the operating room for damage control laparatomy and packing. You notice she is oozing from her central line site. Could this indicate a consumptive coagulopathy? How reliable is the bedside diagnosis of coagulopathy?

There is not sufficient evidence to answer this question in an ED context. There are two types of assessment: in vivo and ex vivo. In vivo assessment of clotting is to a standardized challenge, such as a 1cm long 1mm deep incision or a needlestick. We do not generally use these tests in the ED. However, we are doing procedures and should note any abnormal bleeding and order clotting studies or even empiric FFP.

The ex vivo assessment is more variable because coagulation time is relative to volume. The clotting reaction is initiated at the surface of contact and spreads inward, so smaller volumes clot faster. A droplet of blood during a fingerstick glucose test often clots before the nurse can get the result. That is why the nurse has to do a second stick, rather than continue to squeeze the first. Punguyire, in the Journal of Emergency Medicine recently published an article for resource-limited situations for assessing whether a snakebite is a dry bite. He used a 5mL syringe full of blood and waited 20 minutes to see whether it clotted. The absence of clot was taken to indicate coagulopathy. 

I have sometimes noticed during procedures that rubbing the fingers together enables one to sense how sticky the blood appears to be. I recall a trauma patient with consumptive coagulopathy who kept oozing from the wound, and it felt more like wine than blood. When I felt that, I became a lot more aggressive on FFP transfusion, and made decisions based on bedside findings ahead of pending laboratory results.

Take home points:

-Abnormal bleeding after needlesticks may be the first sign of coagulopathy

-Normal blood in a 5mL syringe should clot within 20 minutes