Prevalence and Impact of Admission Acute Traumatic Coagulopathy on Treatment Intensity, Resource Use, and Mortality: An Evaluation of 956 Severely Injured Children and Adolescents

Abstract

Acute coagulopathy of trauma in children is of potential importance to clinical outcomes, but knowledge is limited and has only been investigated using conventional coagulation testing. The purpose of this study was to assess the prevalence and impact of arrival coagulopathy, determined by viscoelastic hemostatic testing, in severely injured children. Pediatric patients (younger than 17 years of age) who were admitted January 2010 to May 2016 and met highest-level trauma activation were included. Patients were divided into 2 groups (coagulopathy and controls) based on arrival rapid thrombelastography values. Coagulopathy was defined as the presence of any of the following on rapid thrombelastography: activated clotting time ≥128 seconds, α-angle ≤65 degrees, maximum amplitude ≤55mm, and lysis at 30 minutes from 20-mm amplitude ≥3%. Logistic regression was used to adjust for age, sex, blood pressure, mechanism, and injury severity. Nine hundred and fifty-six patients met inclusion; 507 (57%) were coagulopathic and 449(43%) were not (noncoagulopathic and control cohort). Coagulopathic patients were younger (median 14 vs 15 years) and more likely to be male (68% vs 60%) and Hispanic (38% vs 31%) (all p < 0.05). Coagulopathic patients received more RBC and plasma transfusions and had fewer ICU and ventilator-free days and higher mortality (12% vs 3%; all p < 0.05). Of these 956, 197 (21%) sustained severe brain injury-123 (62%) were coagulopathic and 74 (38%) were noncoagulopathic. The mortality difference was even greater for coagulopathic head injuries (31% vs 10%; p= 0.002). Adjusting for confounders, admission coagulopathy was an independent predictor of death, with an odds ratio of 3.67(95% CI 1.768 to 7.632; p < 0.001). Almost 60% of severely injured children and adolescents arrive with evidence of acute traumatic coagulopathy. The presence of admission coagulopathy is associated with high mortality in children, especially among those with head injuries.