Abstract
BackgroundTrauma resuscitation has undergone a paradigm shift with new emphasis on the early use of blood products and increased proportions of plasma and platelets. However, it is unclear how this strategy is applied or how effective it is in the elderly population. The study aim is to identify differences in transfusion practices and the coagulopathy of trauma in the elderly.MethodsData was prospectively collected on all consecutive patients that met trauma activation criteria at a Level I trauma centre. Data fields included patient demographics, co-morbidities, injury and resuscitation data, laboratory values, thromboelastography (TEG) results, and outcome measures. Elderly patients were defined as those 55 and older. Propensity-score matched analysis was completed for patients receiving blood product transfusion. Patients were matched by gender, mechanism, injury severity score (ISS), head injury, and time from injury.ResultsTotal of 628 patients were included, of which 142 (23%) were elderly. Elderly patients were more likely to be female (41% vs. 24%), suffer blunt mechanism of trauma (96% vs. 80%), have higher ISS scores (mean 25.4 vs. 21.6) and mortality (19% vs. 8%). Elderly patients were significantly more likely to receive a blood transfusion (42% vs. 30%), specifically for red cells and plasma. Propensity-matched analysis resulted in no difference in red cell transfusion or mortality. Despite the broad similarities between the matched cohorts, trauma coagulopathy as measured by TEG was less commonly observed in the elderly.DiscussionOur results suggest that elderly trauma patients are more likely to receive blood products when admitted to a trauma centre, though this may be attributed to under-triage. The results also suggest an altered coagulopathic response to traumatic injury which is partially influenced by increased anticoagulant and antiplatelet medication use in the geriatric population.ConclusionIt is not clear whether the acute coagulopathy of trauma is equivalent in geriatric patients, and further study is therefore warranted.
Highlights
Trauma resuscitation has undergone a paradigm shift with new emphasis on the early use of blood products and increased proportions of plasma and platelets
There is even less data on how these new strategies in transfusion have impacted specific subsets of the trauma population, such as the elderly. This shift in transfusion practices has largely been driven by an improved understanding of the coagulopathy of trauma, and the discovery that up to a quarter of severely injured trauma patients will arrive to hospital already in a coagulopathic state [6, 7]
We investigated whether blinded practitioners would follow the clinical practices as proposed by the 2015 expert consensus conference; for example, whether practicing clinicians without access to TEG results would transfuse fresh frozen plasma (FFP) to patients in whom TEG would mandate such transfusion
Summary
Trauma resuscitation has undergone a paradigm shift with new emphasis on the early use of blood products and increased proportions of plasma and platelets. This shift in transfusion practices has largely been driven by an improved understanding of the coagulopathy of trauma, and the discovery that up to a quarter of severely injured trauma patients will arrive to hospital already in a coagulopathic state [6, 7]. This goes beyond the classic triad of hypothermia, hemodilution, and acidosis and involves intrinsic mechanisms such as an accelerated and extensive activation of tissue factor and activated protein C [6, 7].
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