Abnormalities of laboratory coagulation tests versus clinically evident coagulopathic bleeding: results from the prehospital resuscitation on helicopters study (PROHS)

Ronald Chang; Erin E Fox; Thomas J Greene; Michael D Swartz; Stacia M DeSantis; Deborah M Stein; Eileen M Bulger; Sherry M Melton; Michael D Goodman; Martin A Schreiber; Martin D Zielinski; Terence O'Keeffe; Kenji Inaba; Jeffrey S Tomasek; Jeanette M Podbielski; Savitri Appana; Misung Yi; Pär I Johansson; Hanne H Henriksen; Jakob Stensballe; Jacob Steinmetz; Charles E Wade; John B Holcomb; PROHS Study Group

doi:10.1016/j.surg.2017.10.050

Abnormalities of laboratory coagulation tests versus clinically evident coagulopathic bleeding: results from the prehospital resuscitation on helicopters study (PROHS)

Ronald Chang, Erin E Fox, Thomas J Greene, Michael D Swartz, Stacia M DeSantis, Deborah M Stein, Eileen M Bulger, Sherry M Melton, Michael D Goodman, Martin A Schreiber, Martin D Zielinski, Terence O'Keeffe, Kenji Inaba, Jeffrey S Tomasek, Jeanette M Podbielski, Savitri Appana, Misung Yi, Pär I Johansson, Hanne H Henriksen, Jakob StensballeJacob Steinmetz, Charles E Wade, John B Holcomb, PROHS Study Group

Institut for Klinisk Medicin

13 Citationer (Scopus)

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.

Originalsprog	Engelsk
Tidsskrift	Surgery
Vol/bind	163
Udgave nummer	4
Sider (fra-til)	819-826
ISSN	0039-6060
DOI	https://doi.org/10.1016/j.surg.2017.10.050
Status	Udgivet - 1 apr. 2018

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10.1016/j.surg.2017.10.050

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5903880/Licens: Andet

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Chang, R., Fox, E. E., Greene, T. J., Swartz, M. D., DeSantis, S. M., Stein, D. M., Bulger, E. M., Melton, S. M., Goodman, M. D., Schreiber, M. A., Zielinski, M. D., O'Keeffe, T., Inaba, K., Tomasek, J. S., Podbielski, J. M., Appana, S., Yi, M., Johansson, P. I., Henriksen, H. H., ... PROHS Study Group (2018). Abnormalities of laboratory coagulation tests versus clinically evident coagulopathic bleeding: results from the prehospital resuscitation on helicopters study (PROHS). Surgery, 163(4), 819-826. https://doi.org/10.1016/j.surg.2017.10.050

Chang, R, Fox, EE, Greene, TJ, Swartz, MD, DeSantis, SM, Stein, DM, Bulger, EM, Melton, SM, Goodman, MD, Schreiber, MA, Zielinski, MD, O'Keeffe, T, Inaba, K, Tomasek, JS, Podbielski, JM, Appana, S, Yi, M, Johansson, PI, Henriksen, HH, Stensballe, J, Steinmetz, J, Wade, CE, Holcomb, JB & PROHS Study Group 2018, 'Abnormalities of laboratory coagulation tests versus clinically evident coagulopathic bleeding: results from the prehospital resuscitation on helicopters study (PROHS)', Surgery, bind 163, nr. 4, s. 819-826. https://doi.org/10.1016/j.surg.2017.10.050

@inproceedings{144b3d352e344dce9b2bd2aa67e1b7f0,

title = "Abnormalities of laboratory coagulation tests versus clinically evident coagulopathic bleeding: results from the prehospital resuscitation on helicopters study (PROHS)",

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.",

keywords = "Adult, Aged, Air Ambulances, Blood Coagulation Disorders/diagnosis, Emergency Medical Services, Female, Humans, Injury Severity Score, International Normalized Ratio, Male, Middle Aged, Phenotype, Poisson Distribution, Prospective Studies, Regression Analysis, Resuscitation, Thrombelastography, Wounds and Injuries/complications",

author = "Ronald Chang and Fox, {Erin E} and Greene, {Thomas J} and Swartz, {Michael D} and DeSantis, {Stacia M} and Stein, {Deborah M} and Bulger, {Eileen M} and Melton, {Sherry M} and Goodman, {Michael D} and Schreiber, {Martin A} and Zielinski, {Martin D} and Terence O'Keeffe and Kenji Inaba and Tomasek, {Jeffrey S} and Podbielski, {Jeanette M} and Savitri Appana and Misung Yi and Johansson, {P{\"a}r I} and Henriksen, {Hanne H} and Jakob Stensballe and Jacob Steinmetz and Wade, {Charles E} and Holcomb, {John B} and {PROHS Study Group}",

year = "2018",

month = apr,

day = "1",

doi = "10.1016/j.surg.2017.10.050",

language = "English",

volume = "163",

pages = "819--826",

journal = "Surgery (United States)",

issn = "0039-6060",

publisher = "Mosby Inc.",

number = "4",

}

TY - GEN

T1 - Abnormalities of laboratory coagulation tests versus clinically evident coagulopathic bleeding

T2 - results from the prehospital resuscitation on helicopters study (PROHS)

AU - Chang, Ronald

AU - Fox, Erin E

AU - Greene, Thomas J

AU - Swartz, Michael D

AU - DeSantis, Stacia M

AU - Stein, Deborah M

AU - Bulger, Eileen M

AU - Melton, Sherry M

AU - Goodman, Michael D

AU - Schreiber, Martin A

AU - Zielinski, Martin D

AU - O'Keeffe, Terence

AU - Inaba, Kenji

AU - Tomasek, Jeffrey S

AU - Podbielski, Jeanette M

AU - Appana, Savitri

AU - Yi, Misung

AU - Johansson, Pär I

AU - Henriksen, Hanne H

AU - Stensballe, Jakob

AU - Steinmetz, Jacob

AU - Wade, Charles E

AU - Holcomb, John B

AU - PROHS Study Group

PY - 2018/4/1

Y1 - 2018/4/1

N2 - 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.

AB - 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.

KW - Adult

KW - Aged

KW - Air Ambulances

KW - Blood Coagulation Disorders/diagnosis

KW - Emergency Medical Services

KW - Female

KW - Humans

KW - Injury Severity Score

KW - International Normalized Ratio

KW - Male

KW - Middle Aged

KW - Phenotype

KW - Poisson Distribution

KW - Prospective Studies

KW - Regression Analysis

KW - Resuscitation

KW - Thrombelastography

KW - Wounds and Injuries/complications

U2 - 10.1016/j.surg.2017.10.050

DO - 10.1016/j.surg.2017.10.050

M3 - Conference article

C2 - 29289392

SN - 0039-6060

VL - 163

SP - 819

EP - 826

JO - Surgery (United States)

JF - Surgery (United States)

IS - 4

ER -

Abnormalities of laboratory coagulation tests versus clinically evident coagulopathic bleeding: results from the prehospital resuscitation on helicopters study (PROHS)

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