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

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

N1 - Copyright © 2017 Elsevier Inc. All rights reserved.

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 -