Original article
Early evaluation of acute traumatic coagulopathy by thrombelastography

https://doi.org/10.1016/j.trsl.2009.04.001Get rights and content

Posttraumatic coagulopathy is a major cause of morbidity. This prospective study evaluated the thrombelastography (TEG) system and PlateletMapping (Haemoscope Corporation, Niles, Ill) values posttrauma, and it correlated those values with transfusions and fatalities. After institutional review board approval, assays were performed on 161 trauma patients. One citrated blood sample was collected onsite (OS), and 1 citrate and 1 heparinized sample were collected within 1 h of arrival to the emergency department (ED). Paired and unpaired t-testing was performed for nominal data with chi square testing for categorical values. Except for a slight increase in clot strength (maximal amplitude [MA]), there were no significant changes from OS to the ED. None of the TEG parameters were significantly different for the 22 patients who required transfusion. PlateletMapping showed lower platelet adenosine diphosphate (ADP) responsiveness in patients who needed transfusions (MA = 22.7 ± 17.1 vs MA = 35.7 ± 19.3, P = 0.004) and a correlation of fibrinogen <100 mg/dL with fatalities (P = 0.013). For the 14 fatalities, TEG reaction (R) time was 3703 ± 11,618 versus 270 ± 393 s (P = < 0.001), and MA was 46.4 ± 22.4 versus 64.7 ± 9.8 mm (P < 0.001). Hyperfibrinolysis (percent fibrinolysis after 60 min [LY60] >15%) was observed in 3 patients in the ED with a 67% fatality rate (P = < 0.001 by chi-square testing). PlateletMapping assays correlated with the need for blood transfusion. The abnormal TEG System parameters correlated with fatality. These coagulopathies were already evident OS. The TEG assays can assess coagulopathy, platelet dysfunction, and hyperfibrinolysis at an early stage posttrauma and suggest more effective interventions.

Section snippets

Methods

After institutional review board approval, TEG Hemostasis System (Haemoscope Corporation) assays were performed on 161 severely injured trauma patients brought to a level 1 trauma center by air ambulance over a 12-month period. Because most of these patients would be unconscious, and the next of kin was not readily available, the requirement for informed consent was waived. Inclusion criteria were severe injury (injury severity score > 9) and air ambulance transport. There were no exclusion

Results

Patient characteristics are given in Table I. It should be noted that 15 patients were classified as being in shock, which is defined as a systolic blood pressure ≤ 90. Most patients had multiple trauma (32%) and multiple fractures (32%), which mostly result from motor vehicle collisions. Standard coagulation and blood parameters are given in Table II.

To assess the time line of coagulopathy posttrauma, the standard TEG parameters (shown in Fig 1) from OS and ED samples (an average of 45 min

Discussion

Coagulopathy has long been recognized as a major contributor to posttraumatic fatality. Shock and hypoperfusion coupled with massive tissue factor release from injured tissue can lead to an overactivation of the thrombin-thrombomodulin-protein C pathway.2, 3, 4, 5, 10 This can result in the systemic destruction of factor V and VIII and impairment of coagulation. This study demonstrates that coagulopathy can be detected very quickly after trauma. The most common coagulopathy was a prolonged R,

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    Supported by Haemoscope Corporation, and 1 author (R.C.C.) is a paid consultant for Haemoscope Corporation.

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