BACKGROUND: Acute traumatic coagulopathy (ATC) occurs after severe injury and shock and is associated with increased bleeding, morbidity, and mortality. The effects of ATC and hemostatic resuscitation on outcome are not well-explored. The PRospective Observational Multicenter Major Trauma Transfusion (PROMMTT) study provided a unique opportunity to characterize coagulation and the effects of resuscitation on ATC after severe trauma. METHODS: Blood samples were collected upon arrival on a subset of PROMMTT patients. Plasma clotting factor levels were prospectively assayed for coagulation factors. These data were analyzed with comprehensive PROMMTT clinical data. RESULTS: There were 1,198 patients with laboratory results, of whom 41.6% were coagulopathic. Using international normalized ratio of 1.3 or greater, 41.6% of patients (448) were coagulopathic, while 20.5% (214) were coagulopathic using partial thromboplastin time of 35 or greater. Coagulopathy was primarily associated with a combination of an Injury Severity Score (ISS) of greater than 15 and a base deficit (BD) of less than -6 (p < 0.05). Regression modeling for international normalized ratio-based coagulopathy shows that prehospital crystalloid (odds ratio [OR], 1.05), ISS (OR, 1.03), Glasgow Coma Scale (GCS) score (OR, 0.93), heart rate (OR, 1.08), systolic blood pressure (OR, 0.96), BD (OR, 0.92), and temperature (OR, 0.84) were significant predictors of coagulopathy (all p < 0.03). A subset of 165 patients had blood samples collected and coagulation factor analysis performed. Elevated ISS and BD were associated with elevation of aPC and depletion of factors (all p < 0.05). Reductions in factors I, II, V, VIII and an increase in aPC drive ATC (all p < 0.04). Similar results were found for partial thromboplastin time-defined coagulopathy. CONCLUSION: ATC is associated with the depletion of factors I, II, V, VII, VIII, IX, and X and is driven by the activation of the protein C system. These data provide additional mechanistic understanding of the drivers of coagulation abnormalities after injury. Further understanding of the drivers of ATC and the effects of resuscitation can guide factor-guided resuscitation and correction of coagulopathy after injury.
BACKGROUND: Acute traumatic coagulopathy (ATC) occurs after severe injury and shock and is associated with increased bleeding, morbidity, and mortality. The effects of ATC and hemostatic resuscitation on outcome are not well-explored. The PRospective Observational Multicenter Major Trauma Transfusion (PROMMTT) study provided a unique opportunity to characterize coagulation and the effects of resuscitation on ATC after severe trauma. METHODS: Blood samples were collected upon arrival on a subset of PROMMTT patients. Plasma clotting factor levels were prospectively assayed for coagulation factors. These data were analyzed with comprehensive PROMMTT clinical data. RESULTS: There were 1,198 patients with laboratory results, of whom 41.6% were coagulopathic. Using international normalized ratio of 1.3 or greater, 41.6% of patients (448) were coagulopathic, while 20.5% (214) were coagulopathic using partial thromboplastin time of 35 or greater. Coagulopathy was primarily associated with a combination of an Injury Severity Score (ISS) of greater than 15 and a base deficit (BD) of less than -6 (p < 0.05). Regression modeling for international normalized ratio-based coagulopathy shows that prehospital crystalloid (odds ratio [OR], 1.05), ISS (OR, 1.03), Glasgow Coma Scale (GCS) score (OR, 0.93), heart rate (OR, 1.08), systolic blood pressure (OR, 0.96), BD (OR, 0.92), and temperature (OR, 0.84) were significant predictors of coagulopathy (all p < 0.03). A subset of 165 patients had blood samples collected and coagulation factor analysis performed. Elevated ISS and BD were associated with elevation of aPC and depletion of factors (all p < 0.05). Reductions in factors I, II, V, VIII and an increase in aPC drive ATC (all p < 0.04). Similar results were found for partial thromboplastin time-defined coagulopathy. CONCLUSION: ATC is associated with the depletion of factors I, II, V, VII, VIII, IX, and X and is driven by the activation of the protein C system. These data provide additional mechanistic understanding of the drivers of coagulation abnormalities after injury. Further understanding of the drivers of ATC and the effects of resuscitation can guide factor-guided resuscitation and correction of coagulopathy after injury.
Authors: Sandro B Rizoli; Sandro Scarpelini; Jeannie Callum; Bartolomeu Nascimento; Kenneth G Mann; Ruxandra Pinto; Jan Jansen; Homer C Tien Journal: J Trauma Date: 2011-11
Authors: Lisa M Brown; Seppo O Aro; Mitchell J Cohen; J B Holcomb; C E Wade; K J Brasel; G Vercruysse; J MacLeod; R P Dutton; J R Hess; J C Duchesne; N E McSwain; P Muskat; J Johannigamn; H M Cryer; A Tillou; J F Pittet; P Knudson; M A De Moya; M A Schreiber; B Tieu; S Brundage; L M Napolitano; M Brunsvold; K C Sihler; G Beilman; A B Peitzman; M S Zenait; J Sperry; L Alarcon; M A Croce; J P Minei; R Kozar; E A Gonzalez; R M Stewart; S M Cohn; J E Mickalek; E M Bulger; B A Cotton; T C Nunez; R Ivatury; J W Meredith; P Miller; G J Pomper; B Marin Journal: J Trauma Date: 2011-08
Authors: Shibani Pati; Aarif Y Khakoo; Jing Zhao; Fernando Jimenez; Michael H Gerber; Matthew Harting; John B Redell; Raymond Grill; Yoichi Matsuo; Sushovan Guha; Charles S Cox; Marvin S Reitz; John B Holcomb; Pramod K Dash Journal: Stem Cells Dev Date: 2010-10-18 Impact factor: 3.272
Authors: Mitchell Jay Cohen; Mariah Call; Mary Nelson; Carolyn S Calfee; Charles T Esmon; Karim Brohi; Jean Francois Pittet Journal: Ann Surg Date: 2012-02 Impact factor: 12.969
Authors: Benny Sørensen; Mariann Tang; Ole H Larsen; Peter N Laursen; Christian Fenger-Eriksen; Catherine J Rea Journal: Thromb Res Date: 2011 Impact factor: 3.944
Authors: M A Borgman; P C Spinella; J B Holcomb; L H Blackbourne; C E Wade; R Lefering; B Bouillon; M Maegele Journal: Vox Sang Date: 2011-03-25 Impact factor: 2.144
Authors: Brian B Chesebro; Pamela Rahn; Michel Carles; Charles T Esmon; Jun Xu; Karim Brohi; Daniel Frith; Jean-François Pittet; Mitchell J Cohen Journal: Shock Date: 2009-12 Impact factor: 3.454
Authors: Ross Davenport; Joanna Manson; Henry De'Ath; Sean Platton; Amy Coates; Shubha Allard; Daniel Hart; Rupert Pearse; K John Pasi; Peter MacCallum; Simon Stanworth; Karim Brohi Journal: Crit Care Med Date: 2011-12 Impact factor: 7.598
Authors: Gregory R Stettler; Ernest E Moore; Hunter B Moore; Geoffrey R Nunns; Julia R Coleman; Arthur Colvis; Arsen Ghasabyan; Mitchell J Cohen; Christopher C Silliman; Anirban Banerjee; Angela Sauaia Journal: J Trauma Acute Care Surg Date: 2019-09 Impact factor: 3.313
Authors: Benjamin M Howard; Byron Y Miyazawa; Weifeng Dong; Wendy J Cedron; Ryan F Vilardi; Wolfram Ruf; Mitchell Jay Cohen Journal: J Trauma Acute Care Surg Date: 2015-12 Impact factor: 3.313
Authors: Heather F Pidcoke; Claire L Isbell; Maryanne C Herzig; Chriselda G Fedyk; Beverly S Schaffer; Kevin K Chung; Christopher E White; Steven E Wolf; Charles E Wade; Andrew P Cap Journal: J Trauma Acute Care Surg Date: 2015-06 Impact factor: 3.313
Authors: Nicolas J Prat; Andrew D Meyer; Nichole K Ingalls; Julie Trichereau; Joseph J DuBose; Andrew P Cap Journal: J Trauma Acute Care Surg Date: 2017-09 Impact factor: 3.313
Authors: Jason M Samuels; Ernest E Moore; Christopher C Silliman; Anirban Banerjee; Mitchell J Cohen; Arsen Ghasabyan; James Chandler; Julia R Coleman; Angela Sauaia Journal: J Trauma Acute Care Surg Date: 2019-04 Impact factor: 3.313
Authors: Theresa L Chin; Ernest E Moore; Hunter B Moore; Eduardo Gonzalez; Michael P Chapman; John R Stringham; Christopher R Ramos; Anirban Banerjee; Angela Sauaia Journal: Surgery Date: 2014-06-21 Impact factor: 3.982