Hemostasis during the early stages of trauma: comparison with disseminated intravascular coagulation.

Akiko Oshiro,Naomi Henzan,Isao Takahashi,Hiroshi Makise,Yuichiro Yanagida,Satoshi Gando

doi:10.1186/cc13816

Abstract

IntroductionWe tested two hypotheses that disseminated intravascular coagulation (DIC) and acute coagulopathy of trauma-shock (ACOTS) in the early phase of trauma are similar disease entities and that the DIC score on admission can be used to predict the prognosis of patients with coagulopathy of trauma.MethodsWe conducted a retrospective study of 562 trauma patients, including 338 patients whose data were obtained immediately after admission to the emergency department. We collected serial data for the platelet counts, global markers of coagulation and fibrinolysis, and antithrombin levels. DIC was diagnosed according to the Japanese Association for Acute Medicine (JAAM) DIC scoring system, and ACOTS was defined as a prothrombin-time ratio of >1.2.ResultsThe higher levels of fibrin/fibrinogen degradation products (FDP) and D-dimer and greater FDP/D-dimer ratios in the DIC patients suggested DIC with the fibrinolytic phenotype. The DIC patients with the fibrinolytic phenotype exhibited persistently lower platelet counts and fibrinogen levels, increased prothrombin time ratios, higher FDP and D-dimer levels, and lower antithrombin levels compared with the non-DIC patients on arrival to the emergency department and during the early stage of trauma. Almost all ACOTS patients met the criteria for a diagnosis of DIC; therefore, the same changes were observed in the platelet counts, global markers of coagulation and fibrinolysis, and antithrombin levels as noted in the DIC patients. The JAAM DIC score obtained immediately after arrival to the emergency department was an independent predictor of massive transfusion and death due to trauma and correlated with the amount of blood transfused.ConclusionsPatients who develop DIC with the fibrinolytic phenotype during the early stage of trauma exhibit consumption coagulopathy associated with increased fibrin(ogen)olysis and lower levels of antithrombin. The same is true in patients with ACOTS. The JAAM DIC score can be used to predict the prognosis of patients with coagulopathy of trauma.

Highlights

We tested two hypotheses that disseminated intravascular coagulation (DIC) and acute coagulopathy of trauma-shock (ACOTS) in the early phase of trauma are similar disease entities and that the DIC score on admission can be used to predict the prognosis of patients with coagulopathy of trauma
The Japanese Association for Acute Medicine (JAAM) DIC patients, especially those who simultaneously met the International Society on Thrombosis and Haemostasis (ISTH) overt DIC criteria, had more serious injuries and higher Acute Physiology and Chronic Health Evaluation (APACHE) Acute Physiology and Chronic Health Evaluation II (II) and Sequential Organ Failure Assessment (SOFA) scores, exhibiting poor outcomes associated with Multiple organ dysfunction syndrome (MODS)
These results demonstrated that the prognosis of the trauma patients deteriorated in accordance with increasing abnormalities of coagulation and fibrinolysis

Summary

Introduction

We tested two hypotheses that disseminated intravascular coagulation (DIC) and acute coagulopathy of trauma-shock (ACOTS) in the early phase of trauma are similar disease entities and that the DIC score on admission can be used to predict the prognosis of patients with coagulopathy of trauma. Reconfirmed that trauma itself is the main cause of coagulopathy of trauma [2] Based on this discovery, another concept of coagulopathy of trauma called acute coagulopathy of trauma-shock (ACOTS) was established as a distinct disease entity distinct from DIC [6,7]. Another concept of coagulopathy of trauma called acute coagulopathy of trauma-shock (ACOTS) was established as a distinct disease entity distinct from DIC [6,7] In this concept, ACOTS, not DIC, is considered to be the primary pathophysiological mechanism of coagulopathy of trauma. The authors asserted that no evidence implicates the process of DIC in the development of coagulopathy of trauma [6,7,8] Legitimate rebuttals of these concepts have reviewed the similarities and differences in DIC and ACOTS and reconfirmed the appropriateness of the DIC concept [9,10]. Data regarding serial changes in the platelet counts and global markers of coagulation and fibrinolysis in patients with ACOTS are lacking

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