Joshua J Sumislawski1, S Ariane Christie2, Lucy Z Kornblith3, Gregory R Stettler4, Geoffrey R Nunns5, Hunter B Moore6, Ernest E Moore7, Christopher C Silliman8, Angela Sauaia9, Rachael A Callcut10, Mitchell Jay Cohen11. 1. Department of Surgery, Denver Health Medical Center, University of Colorado, 777 Bannock Street, MC 0206, Denver, CO, 80204, United States. Electronic address: joshua.sumislawski@ucdenver.edu. 2. Department of Surgery, Zuckerberg San Francisco General Hospital, University of California San Francisco, 1001 Potrero Avenue, Ward 3A, San Francisco, CA, 94110, United States. Electronic address: sabrinah.christie@ucsf.edu. 3. Department of Surgery, Zuckerberg San Francisco General Hospital, University of California San Francisco, 1001 Potrero Avenue, Ward 3A, San Francisco, CA, 94110, United States. Electronic address: lucy.kornblith@ucsf.edu. 4. Department of Surgery, Denver Health Medical Center, University of Colorado, 777 Bannock Street, MC 0206, Denver, CO, 80204, United States. Electronic address: gregory.stettler@ucdenver.edu. 5. Department of Surgery, Denver Health Medical Center, University of Colorado, 777 Bannock Street, MC 0206, Denver, CO, 80204, United States. Electronic address: geoffrey.nunns@ucdenver.edu. 6. Department of Surgery, Denver Health Medical Center, University of Colorado, 777 Bannock Street, MC 0206, Denver, CO, 80204, United States. Electronic address: hunter.moore@ucdenver.edu. 7. Department of Surgery, Denver Health Medical Center, University of Colorado, 777 Bannock Street, MC 0206, Denver, CO, 80204, United States. Electronic address: ernest.moore@dhha.org. 8. Department of Pediatrics, Children's Hospital Colorado, University of Colorado, 13123 East 16th Avenue, Aurora, CO, 80045, United States. Electronic address: christopher.silliman@ucdenver.edu. 9. Department of Surgery, Denver Health Medical Center, University of Colorado, 777 Bannock Street, MC 0206, Denver, CO, 80204, United States. Electronic address: angela.sauaia@ucdenver.edu. 10. Department of Surgery, Zuckerberg San Francisco General Hospital, University of California San Francisco, 1001 Potrero Avenue, Ward 3A, San Francisco, CA, 94110, United States. Electronic address: rachael.callcut@ucsf.edu. 11. Department of Surgery, Denver Health Medical Center, University of Colorado, 777 Bannock Street, MC 0206, Denver, CO, 80204, United States. Electronic address: mitchell.cohen@dhha.org.
Abstract
BACKGROUND: Trauma-induced coagulopathy can present as abnormalities in a conventional or viscoelastic coagulation assay or both. We hypothesized that patients with discordant coagulopathies reflect different clinical phenotypes. METHODS: Blood samples were collected prospectively from critically injured patients upon arrival at two urban Level I trauma centers. International normalized ratio (INR), partial thromboplastin time (PTT), thromboelastography (TEG), and coagulation factors were assayed. RESULTS: 278 patients (median ISS 17, mortality 26%) were coagulopathic: 20% with isolated abnormal INR and/or PTT (CONVENTIONAL), 49% with isolated abnormal TEG (VISCOELASTIC), and 31% with abnormal INR/PTT and TEG (BOTH). Compared with VISCOELASTIC, CONVENTIONAL and BOTH had higher ISS, lower GCS, larger base deficit, and decreased factor activities (all p < 0.017). They received more blood products and had more ICU/ventilation days (all p < 0.017). Mortality was higher in CONVENTIONAL (40%) and BOTH (49%) than VISCOELASTIC (6%, p < 0.017). CONCLUSIONS: Although TEG-guided resuscitation improves survival after injury, INR and PTT identify coagulopathic patients with highest mortality regardless of TEG and likely represent distinct mechanisms independent of biochemical clot strength.
BACKGROUND:Trauma-induced coagulopathy can present as abnormalities in a conventional or viscoelastic coagulation assay or both. We hypothesized that patients with discordant coagulopathies reflect different clinical phenotypes. METHODS: Blood samples were collected prospectively from critically injured patients upon arrival at two urban Level I trauma centers. International normalized ratio (INR), partial thromboplastin time (PTT), thromboelastography (TEG), and coagulation factors were assayed. RESULTS: 278 patients (median ISS 17, mortality 26%) were coagulopathic: 20% with isolated abnormal INR and/or PTT (CONVENTIONAL), 49% with isolated abnormal TEG (VISCOELASTIC), and 31% with abnormal INR/PTT and TEG (BOTH). Compared with VISCOELASTIC, CONVENTIONAL and BOTH had higher ISS, lower GCS, larger base deficit, and decreased factor activities (all p < 0.017). They received more blood products and had more ICU/ventilation days (all p < 0.017). Mortality was higher in CONVENTIONAL (40%) and BOTH (49%) than VISCOELASTIC (6%, p < 0.017). CONCLUSIONS: Although TEG-guided resuscitation improves survival after injury, INR and PTT identify coagulopathic patients with highest mortality regardless of TEG and likely represent distinct mechanisms independent of biochemical clot strength.
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