Early coagulopathy in trauma patients: An on-scene and hospital admission study
Introduction
The development of coagulation abnormalities is frequent in severe trauma and contributes significantly to the morbidity and the mortality.14, 33 Haemorrhage accounts for 40% of all trauma deaths.33 In the pre-hospital setting, uncontrolled bleeding is the second most common cause of death after central nervous system injuries26 and the first responsible for early in-hospital mortality from major trauma.33 The triad of coagulopathy, acidosis and hypothermia in trauma patients is associated with a high mortality.8, 34, 36
The pathogenesis of severe post-traumatic coagulopathy is complex and multifactorial.17, 18, 34 Six major events appear as contributing to post-traumatic coagulopathy: tissue trauma, shock, haemodilution, hypothermia, acidemia and inflammation.10, 17 In combination, direct tissue trauma and shock with systemic hypoperfusion appear to be the primary factors responsible for the development of coagulopathy in the immediate post-injury phase. Other factors as acidosis, hypothermia and haemodilution may be important later in the clinical course.17 A profile of coagulopathy secondary to the extravasation of tissue factor and hypoperfusion is associated with poor outcome such as multiple organ failure and death.6, 13, 14, 24 A recent review suggests that most early trauma-associated coagulopathy (TAC) is a result of enhanced activity of plasma coagulation during the initial phase.17 This phenomenon is not a disseminated intravascular coagulation (DIC) as described in sepsis.21 It is marked by early onset, prolonged prothrombin time and activated partial thromboplastin time and a relative sparing of platelets and fibrinogen.17
Recent studies have described an early post-traumatic coagulopathy in 24–36% of trauma patients upon admission to the emergency room.7, 19, 27, 28 In all these studies, the mean time from injury to arrival in the emergency room was 75 min. This early coagulopathy was a marker of injury severity and was related to mortality. However, up to this date there have been no prospective studies evaluating the initial coagulation status in the pre-hospital setting. Our hypothesis was that coagulation abnormalities became apparent very early, at the site of the accident.
The aim of this prospective study was to describe the on-scene and on hospital arrival coagulation profile in trauma patients.
Section snippets
Study sample
This single-centre, prospective, observational study was approved by our hospital research ethics committee. Waived informed consent was authorised by the committee as this study did not impact patient care and did not change local practices. All trauma patients managed by a mobile intensive care unit (SAMU system) and admitted to the trauma resuscitation room (TRU) of our level 1 trauma centre between May and June 2007 were included. The SAMU system has been described elsewhere.31 On-scene
Characteristics of the study sample
During the study period, 45 patients were included. No patients were excluded. General characteristics of the study patients are given in Table 2. The median AIS for head was 1.5 (0–4.5). Fourteen patients (31%) presented a head injury with an AIS ≥3. Times from injury to team's ambulance arrival and from injury to arrival in the emergency room are presented in Table 2. The median systolic arterial pressure was 120 mm Hg (98–130) on-scene and 120 mm Hg (110–130) at the hospital admission. The
Discussion
The present results indicate that in a group with significant injuries more than half of patients presented coagulation abnormalities on-scene. This coagulopathy developed early after injury and before fluid administration. In the TRU, coagulopathy was present in 60% of the patients. Upon hospital admission, the on-scene coagulopathy was spontaneously normalised only in 2 patients when others had the same or a worsened coagulopathy status. The time from injury to arrival in hospital and the
Conclusion
Our results demonstrate that coagulation abnormalities appear very early after injury and are, thus, observed on-scene. This coagulopathy is present before fluid administration. Coagulation status was abnormal in 60% of patients. Upon hospital admission, the on-scene coagulopathy was the same or worsened in 96% of the patients. Every marker of coagulation was modified on hospital admission. Decreases in protein C activities were related to the coagulation status and changes in other coagulation
Conflict of interest statement
All authors attest they have no conflicts of interest.
Role of the funding source
Support was provided only by institutional sources.
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