Abstract
BackgroundSevere injury induces an acute coagulopathy associated with increased mortality. This study compared the Thrombelastography (TEG) and biomarker profiles upon admission in trauma patients.MethodsProspective observational study of 80 trauma patients admitted to a Level I Trauma Centre. Data on demography, biochemistry including standard coagulation tests, hematology, transfusions, Injury Severity Score (ISS) and TEG were recorded. Retrospective analysis of thawed plasma/serum for biomarkers reflecting tissue injury (histone-complexed DNA fragments), sympathoadrenal activation (adrenaline, noradrenaline), coagulation activation/inhibition and fibrinolysis (sCD40L, protein C, activated Protein C, tissue-type plasminogen activator, plasminogen activator inhibitor-1, D-dimer, prothrombinfragment 1+2, plasmin/α2-antiplasmin complex, thrombin/antithrombin complex, tissue factor pathway inhibitor, antithrombin, von willebrand factor, factor XIII). Comparison of patients stratified according to ISS/TEG maximum clot strength. Linear regression analysis of variables associated with clot strength.ResultsTrauma patients had normal (86%), hypercoagulable (11%) or hypocoagulable (1%) TEG clot strength; one had primary hyperfibrinolysis. Hypercoagulable patients had higher age, fibrinogen and platelet count (all p < 0.05), none had increased activated partial thromboplastin time (APTT) or international normalized ratio (INR) and none required massive transfusion (> 10 red blood cells the initial 24 h). Patients with normal or hypercoagulable TEG clot strength had comparable biomarker profiles, but the few patients with hypocoagulable TEG clot strength and/or hyperfibrinolysis had very different biomarker profiles.Increasing ISS was associated with higher levels of catecholamines, histone-complexed DNA fragments, sCD40L, activated protein C and D-dimer and reduced levels of non-activated protein C, antithrombin, fibrinogen and factor XIII (all p < 0.05). Fibrinogen and platelet count were associated independently with clot strength in patients with ISS ≤ 26 whereas only fibrinogen was associated independently with clot strength in patients with ISS > 26. In patients with ISS > 26, adrenaline and sCD40L were independently negatively associated with clot strength.ConclusionsTrauma patients displayed different coagulopathies by TEG and variables independently associated with clot strength changed with ISS. In the highest ISS group, adrenaline and sCD40L were independently negatively associated with clot strength indicating that these may contribute to acute coagulopathy.
Highlights
Severe injury induces an acute coagulopathy associated with increased mortality
Many severely injured patients develop an acute coagulopathy of trauma (ACT) already at the scene of the accident [1,2] and 25-35% are coagulopathic upon admission, a condition associated with a four-fold increase in mortality [3]
Injury severity and predictors of maximum clot strength Given that platelets, fibrinogen and factor XIII (FXIII) contribute significantly to TEG clot strength [23,24,25], we investigated the association between these variables and maximum clot strength in patients stratified according to Injury Severity Score (ISS) and investigated the influence of the measured biomarkers on the independent association between fibrinogen, platelet count, FXIII and clot strength (Table 3)
Summary
Severe injury induces an acute coagulopathy associated with increased mortality. This study compared the Thrombelastography (TEG) and biomarker profiles upon admission in trauma patients. No studies have directly compared outcomes in ratio-driven vs TEG guided resuscitated bleeding trauma patients, and in addition to our previous finding of improved survival in bleeding patients resuscitated goal-directed according to TEG [14] we recently reported, in a meta-analysis of 16 studies of massively bleeding trauma patients, that the highest ratio of FFP and/or PLT to RBC was associated with a significantly reduced mortality (OR 0.49 (95% CI 0.43-0.57), p < 0.0001) as compared to the lowest ratio [15]. TEG/ ROTEM were recently recommended internationally as gold standard point-of-care tests in bleeding trauma patients [16,17]
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