Background considerations 

• Cirrhotic patients tend to have higher morbidity and mortality with trauma-related injuries.
• No strict guidelines exist for traumatic intracranial hemorrhage and coagulopathy reversal in the cirrhotic trauma patient.
• Cirrhotic patients have a complex hemostatic profile. While at risk for bleeding episodes, they are also at high risk for thrombotic events regardless of their laboratory values (PT/INR, PTT).
• Global assays such as thromboelastography (TEG) or thromboelastometry (ROTEM) have been shown in some studies to be more useful tests in determining a true hemostatic state.

Management

• INR: May be elevated in cirrhosis but it is not a true reflection of bleeding risk and correcting it to reach a target numerical value comes with significant risks (administration of FFP may increase blood pressure, portal pressure due to volume overload)
• Platelets: Thrombocytopenia can be common as well as co-existent platelet dysfunction; typically transfuse if < 100k in the setting of active severe bleeding
• Fibrinogen: Essential for clot formation, consider presence of hypofibrinogenemia or dysfibrinogenemia in cirrhosis; if fibrinogen level less than 100-150, consider cryoprecipitate transfusion (1 unit per 10 kg)

References:

1. Northup, PG; et al. Coagulation in liver disease. Clin Gastroenterol Hepatol. 2013 Sep;11(9):1064-74. doi: 10.1016/j.cgh.2013.02.026. Epub 2013 Mar 16.
2. Schaden E, et al. Coagulation pattern in critical liver dysfunction. Curr Opin Crit Care. 2013 Apr;19(2):142-8. doi: 10.1097/MCC.0b013e32835ebb52.
3. Tripodi A, et al. The coagulopathy of chronic liver disease. N Engl J Med. 2011 Jul 14;365(2):147-56. doi: 10.1056/NEJMra1011170.