Ronald Chang1, Erin E Fox2, Thomas J Greene3, Michael D Swartz4, Stacia M DeSantis3, Deborah M Stein5, Eileen M Bulger6, Sherry M Melton7, Michael D Goodman8, Martin A Schreiber9, Martin D Zielinski10, Terence O'Keeffe11, Kenji Inaba12, Jeffrey S Tomasek2, Jeanette M Podbielski2, Savitri Appana3, Misung Yi3, Pär I Johansson13, Hanne H Henriksen13, Jakob Stensballe14, Jacob Steinmetz15, Charles E Wade16, John B Holcomb16. 1. Center for Translational Injury Research, University of Texas Health Science Center, Houston, TX; Department of Surgery, McGovern Medical School, Houston, TX. Electronic address: ronald.chang@uth.tmc.edu. 2. Center for Translational Injury Research, University of Texas Health Science Center, Houston, TX. 3. Department of Biostatistics, School of Public Health, University of Texas Health Science Center at Houston, Houston, TX. 4. Center for Translational Injury Research, University of Texas Health Science Center, Houston, TX; Department of Biostatistics, School of Public Health, University of Texas Health Science Center at Houston, Houston, TX. 5. Department of Surgery, University of Maryland School of Medicine, Baltimore, MD. 6. Department of Surgery, University of Washington School of Medicine, Seattle, WA. 7. Department of Surgery, New York Health and Hospitals, New York, NY. 8. Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH. 9. Department of Surgery, Oregon Health & Science University, Portland, OR. 10. Department of Surgery, Mayo Clinic, Rochester, MN. 11. Department of Surgery, University of Arizona Health Sciences, Tucson, AZ. 12. Department of Surgery, University of Southern California School of Medicine, Los Angeles, CA. 13. Center for Translational Injury Research, University of Texas Health Science Center, Houston, TX; Section for Transfusion Medicine, Capital Region Blood Bank, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark. 14. Section for Transfusion Medicine, Capital Region Blood Bank, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark; Department of Anesthesia, Centre of Head and Orthopedics, Rigshospitalet, Copenhagen University Hospital, Denmark. 15. Department of Anesthesia, Centre of Head and Orthopedics, Rigshospitalet, Copenhagen University Hospital, Denmark; Helicopter Emergency Medical Service, Denmark. 16. Center for Translational Injury Research, University of Texas Health Science Center, Houston, TX; Department of Surgery, McGovern Medical School, Houston, TX.
Abstract
BACKGROUND: Laboratory-based evidence of coagulopathy (LC) is observed in 25-35% of trauma patients, but clinically-evident coagulopathy (CC) is not well described. METHODS: Prospective observational study of adult trauma patients transported by helicopter from the scene to nine Level 1 trauma centers in 2015. Patients meeting predefined highest-risk criteria were divided into CC+ (predefined as surgeon-confirmed bleeding from uninjured sites or injured sites not controllable by sutures) or CC-. We used a mixed-effects, Poisson regression with robust error variance to test the hypothesis that abnormalities on rapid thrombelastography (r-TEG) and international normalized ratio (INR) were independently associated with CC+. RESULTS: Of 1,019 highest-risk patients, CC+ (n=41, 4%) were more severely injured (median ISS 32 vs 17), had evidence of LC on r-TEG and INR, received more transfused blood products at 4 hours (37 vs 0 units), and had greater 30-day mortality (59% vs 12%) than CC- (n=978, 96%). The overall incidence of LC was 39%. 30-day mortality was 22% vs 9% in those with and without LC. In two separate models, r-TEG K-time >2.5 min (RR 1.3, 95% CI 1.1-1.7), r-TEG mA <55 mm (RR 2.5, 95% CI 2.0-3.2), platelet count <150 x 109/L (RR 1.2, 95% CI 1.1-1.3), and INR >1.5 (RR 5.4, 95% CI 1.8-16.3) were independently associated with CC+. A combined regression model was not generated because too few patients underwent both r-TEG and INR. CONCLUSION: CC was rare compared to LC. CC was associated with poor outcomes and impairment of both clotting factor and platelet-mediated coagulation components.
BACKGROUND: Laboratory-based evidence of coagulopathy (LC) is observed in 25-35% of traumapatients, but clinically-evident coagulopathy (CC) is not well described. METHODS: Prospective observational study of adult traumapatients transported by helicopter from the scene to nine Level 1 trauma centers in 2015. Patients meeting predefined highest-risk criteria were divided into CC+ (predefined as surgeon-confirmed bleeding from uninjured sites or injured sites not controllable by sutures) or CC-. We used a mixed-effects, Poisson regression with robust error variance to test the hypothesis that abnormalities on rapid thrombelastography (r-TEG) and international normalized ratio (INR) were independently associated with CC+. RESULTS: Of 1,019 highest-risk patients, CC+ (n=41, 4%) were more severely injured (median ISS 32 vs 17), had evidence of LC on r-TEG and INR, received more transfused blood products at 4 hours (37 vs 0 units), and had greater 30-day mortality (59% vs 12%) than CC- (n=978, 96%). The overall incidence of LC was 39%. 30-day mortality was 22% vs 9% in those with and without LC. In two separate models, r-TEG K-time >2.5 min (RR 1.3, 95% CI 1.1-1.7), r-TEG mA <55 mm (RR 2.5, 95% CI 2.0-3.2), platelet count <150 x 109/L (RR 1.2, 95% CI 1.1-1.3), and INR >1.5 (RR 5.4, 95% CI 1.8-16.3) were independently associated with CC+. A combined regression model was not generated because too few patients underwent both r-TEG and INR. CONCLUSION: CC was rare compared to LC. CC was associated with poor outcomes and impairment of both clotting factor and platelet-mediated coagulation components.
Authors: Marc Maegele; Max Zinser; Christoph Schlimp; Herbert Schöchl; Dietmar Fries Journal: J Trauma Acute Care Surg Date: 2015-06 Impact factor: 3.313
Authors: Charles E Wade; Lisa A Baer; Jessica C Cardenas; Lindley E Folkerson; Kisha Nutall-Aurora; Bryan A Cotton; Nena Matijevic; John B Holcomb; James M Cross; Todd Huzar Journal: Burns Date: 2016-09-28 Impact factor: 2.744
Authors: Bryan A Cotton; John A Harvin; Vadim Kostousouv; Kristin M Minei; Zayde A Radwan; Herbert Schöchl; Charles E Wade; John B Holcomb; Nena Matijevic Journal: J Trauma Acute Care Surg Date: 2012-08 Impact factor: 3.313
Authors: Matthew E Kutcher; Brittney J Redick; Ryan C McCreery; Ian M Crane; Molly D Greenberg; Leslie M Cachola; Mary F Nelson; Mitchell Jay Cohen Journal: J Trauma Acute Care Surg Date: 2012-07 Impact factor: 3.313
Authors: Francis J Castellino; Michael P Chapman; Deborah L Donahue; Scott Thomas; Ernest E Moore; Max V Wohlauer; Braxton Fritz; Robert Yount; Victoria Ploplis; Patrick Davis; Edward Evans; Mark Walsh Journal: J Trauma Acute Care Surg Date: 2014-05 Impact factor: 3.313
Authors: Michael P Chapman; Ernest E Moore; Hunter B Moore; Eduardo Gonzalez; Fabia Gamboni; James G Chandler; Sanchayita Mitra; Arsen Ghasabyan; Theresa L Chin; Angela Sauaia; Anirban Banerjee; Christopher C Silliman Journal: J Trauma Acute Care Surg Date: 2016-01 Impact factor: 3.313
Authors: Alexander C Schulick; Hunter B Moore; Carson B Walker; Hillary Yaffe; James J Pomposelli; Fareed Azam; Michael Wachs; Thomas Bak; Peter Kennealey; Kendra Conzen; Megan Adams; Thomas Pshak; Rashikh Choudhury; Michael P Chapman; Elizabeth A Pomfret; Trevor L Nydam Journal: Am J Surg Date: 2020-09-01 Impact factor: 2.565
Authors: Grace E Martin; Amanda M Pugh; Ryan Moran; Rose Veile; Lou Ann Friend; Timothy A Pritts; Amy T Makley; Charles C Caldwell; Michael D Goodman Journal: J Trauma Acute Care Surg Date: 2019-04 Impact factor: 3.313
Authors: James Harrington; Ben L Zarzaur; Erin E Fox; Charles E Wade; John B Holcomb; Stephanie A Savage Journal: J Trauma Acute Care Surg Date: 2022-03-01 Impact factor: 3.697
Authors: Francisco Martín-Rodríguez; Raúl López-Izquierdo; Ancor Sanz-García; Carlos Del Pozo Vegas; Miguel Ángel Castro Villamor; Agustín Mayo-Iscar; José L Martín-Conty; Guillermo José Ortega Journal: J Med Syst Date: 2022-05-21 Impact factor: 4.920
Authors: Ernest E Moore; Hunter B Moore; Lucy Z Kornblith; Matthew D Neal; Maureane Hoffman; Nicola J Mutch; Herbert Schöchl; Beverley J Hunt; Angela Sauaia Journal: Nat Rev Dis Primers Date: 2021-04-29 Impact factor: 65.038
Authors: Vladimir Černý; Marc Maegele; Vanessa Agostini; Dietmar Fries; Santiago R Leal-Noval; Gábor Nardai; Giuseppe Nardi; Anders Östlund; Herbert Schöchl Journal: Eur J Trauma Emerg Surg Date: 2021-01-05 Impact factor: 3.693
Authors: Elisabeth C van Turenhout; Sebastiaan M Bossers; Stephan A Loer; Georgios F Giannakopoulos; Lothar A Schwarte; Patrick Schober Journal: Transfus Med Date: 2020-01-05 Impact factor: 2.019
Authors: James H Lantry; Phillip Mason; Matthew G Logsdon; Connor M Bunch; Ethan E Peck; Ernest E Moore; Hunter B Moore; Matthew D Neal; Scott G Thomas; Rashid Z Khan; Laura Gillespie; Charles Florance; Josh Korzan; Fletcher R Preuss; Dan Mason; Tarek Saleh; Mathew K Marsee; Stefani Vande Lune; Qamarnisa Ayoub; Dietmar Fries; Mark M Walsh Journal: J Clin Med Date: 2022-01-12 Impact factor: 4.241