Abstract
IntroductionThe appropriate strategy for trauma-induced coagulopathy management is under debate. We report the treatment of major trauma using mainly coagulation factor concentrates.MethodsThis retrospective analysis included trauma patients who received ≥ 5 units of red blood cell concentrate within 24 hours. Coagulation management was guided by thromboelastometry (ROTEM®). Fibrinogen concentrate was given as first-line haemostatic therapy when maximum clot firmness (MCF) measured by FibTEM (fibrin-based test) was <10 mm. Prothrombin complex concentrate (PCC) was given in case of recent coumarin intake or clotting time measured by extrinsic activation test (EXTEM) >1.5 times normal. Lack of improvement in EXTEM MCF after fibrinogen concentrate administration was an indication for platelet concentrate. The observed mortality was compared with the mortality predicted by the trauma injury severity score (TRISS) and by the revised injury severity classification (RISC) score.ResultsOf 131 patients included, 128 received fibrinogen concentrate as first-line therapy, 98 additionally received PCC, while 3 patients with recent coumarin intake received only PCC. Twelve patients received FFP and 29 received platelet concentrate. The observed mortality was 24.4%, lower than the TRISS mortality of 33.7% (P = 0.032) and the RISC mortality of 28.7% (P > 0.05). After excluding 17 patients with traumatic brain injury, the difference in mortality was 14% observed versus 27.8% predicted by TRISS (P = 0.0018) and 24.3% predicted by RISC (P = 0.014).ConclusionsROTEM®-guided haemostatic therapy, with fibrinogen concentrate as first-line haemostatic therapy and additional PCC, was goal-directed and fast. A favourable survival rate was observed. Prospective, randomized trials to investigate this therapeutic alternative further appear warranted.
Highlights
The appropriate strategy for trauma-induced coagulopathy management is under debate
Fifteen patients who died in the first hour after admission, most of whom arrived under cardio-pulmonary resuscitation, were excluded from the study, together with three patients who received no haemostatic therapy within the first 24 hours
After excluding 17 patients with traumatic brain injury, the difference in mortality was 14% observed versus 27.8% predicted by trauma injury severity score (TRISS) (P = 0.0018) and 24.3% predicted by revised injury severity classification (RISC) (P = 0.014)
Summary
We report the treatment of major trauma using mainly coagulation factor concentrates. Coagulopathy has been shown to be present in approximately 25 to 35% of all trauma patients on admission to the emergency room (ER) [1,2]. This represents a serious problem for major trauma patients and accounts for 40% of all trauma-related deaths [3]. There have not been any studies on the combined use of fibrinogen concentrate and PCC for prompt haemostatic therapy in trauma patients. Goal-directed haemostatic therapy with coagulation factor concentrates may reduce transfusion of allogeneic blood products, which is desirable given their negative impact on the patient outcomes
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