Polytrauma of the German Trauma Society (DGU) Early coagulopathy in multiple injury: an analysis from the German Trauma Registry on 8724 patients

Institute for Research in Operative Medicine (IFOM), Universität Witten/Herdecke, Witten, North Rhine-Westphalia, Germany
Injury (Impact Factor: 2.14). 03/2007; 38(3):298-304. DOI: 10.1016/j.injury.2006.10.003
Source: PubMed


There is increasing evidence for acute traumatic coagulopathy occurring prior to emergency room (ER) admission but detailed information is lacking.
A retrospective analysis using the German Trauma Registry database including 17,200 multiple injured patients was conducted to determine (a) to what extent clinically relevant coagulopathy has already been established upon ER admission, and whether its presence was associated (b) with the amount of intravenous fluids (i.v.) administered pre-clinically, (c) with the magnitude of injury, and (d) with impaired outcome and mortality. Eight thousand seven hundred and twenty-four patients with complete data sets were screened.
Coagulopathy upon ER admission as defined by prothrombin time test (Quick's value) <70% and/or platelets <100,000 microl(-1), was present in 34.2% of all patients. There was an increasing incidence for coagulopathy with increasing amounts of i.v. fluids administered pre-clinically. Coagulopathy was observed in >40% of patients with >2000 ml, in >50% with >3000 ml, and in >70% with >4000 ml administered. Ten percentage of patients presented with clotting disorders although pre-clinical resuscitation was limited to 500 ml of i.v. fluids maximum. The mean ISS score in the coagulopathy group was 30 (S.D. 15) versus 21 (S.D. 12) (p<0.001). Twenty-nine percentage of patients with coagulopathy developed multi organ failure (p<0.001). Early in-hospital mortality (<24h) was 13% in patients with coagulopathy (p<0.001) and overall in-hospital mortality totalled 28% (p<0.001).
There is a high frequency of established coagulopathy in multiple injury upon ER admission. The presence of early traumatic coagulopathy was associated with the amount of intravenous fluids administered pre-clinically, magnitude of injury, and impaired outcome.

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    • "However, patients with vs. without haemorrhagic shock had comparable injury severity (measured by AIS) of the head, face, neck and thorax, but significantly higher AIS values of the abdomen (liver, spleen) or extremities (pelvis, femur) (p < 0.001). As in previous investigations [6] [7], admission blood glucose showed only a low correlation, and no co-linearity to other welldocumented factors for outcome and/or injury severity prediction such as lactate, pH, bicarbonate, standard base excess, and haemoglobin (data not shown) [19] [20] [21] [22]. These factors are, at least in part, influenced by the type and amount of fluids being administered pre-hospitally. "
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    ABSTRACT: Introduction Admission blood glucose is known to be a predictor for outcome in several disease patterns, especially in critically ill trauma patients. The underlying mechanisms for the association of hyperglycaemia and poor outcome are still not proven. It was hypothesised that hyperglycaemia upon hospital admission is associated with haemorrhagic shock and in-hospital mortality. Methods Data was extracted from an observational trauma database of the level 1 trauma centre at Innsbruck Medical University hospital. Trauma patients (≥18 years) with multiple injuries and an Injury Severity Score ≥17 were included and analysed. Results In total, 279 patients were analysed, of which 42 patients (15.1%) died. With increasing blood glucose upon hospital admission, the rate of patients with haemorrhagic shock rose significantly [from 4.4% (glucose 4.1-5.5 mmol/L) to 87.5% (glucose >15 mmol/L), p < 0.0001]. Mortality was also associated with initial blood glucose [≤5.50 mmol/L 8.3%; 5.51-7.50 mmol/L 10.9%, 7.51-10 mmol/L 12.4%; 10.01-15 mmol/L 32.0%; ≥15.01 mmol/L 12.5%, p = 0.008]. Admission blood glucose was a better indicator for haemorrhagic shock (cut-off 9.4 mmol/L, sensitivity 67.1%, specificity 83.9%) than haemoglobin, base excess, bicarbonate, pH, lactate, or vital parameters. Regarding haemorrhagic shock, admission blood glucose is more valuable during initial patient assessment than the second best predictive parameter, which was admission haemoglobin (cut-off value 6.5 mmol/L (10.4 g/dL): sensitivity 61.3%, specificity 83.9%). Conclusions In multiple trauma, non-diabetic patients, admission blood glucose predicted the incidence of haemorrhagic shock. Admission blood glucose is an inexpensive, rapidly and easily available laboratory value that might help to identify patients at risk for haemorrhagic shock during initial evaluation upon hospital admission.
    Full-text · Article · Sep 2014 · Injury
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    • "Evaluation of patients with torso trauma is often a diagnostic challenge for emergency physicians and trauma surgeons. Uncontrolled hemorrhage is responsible for over 50% of trauma related deaths [1] [2] [3]. Significant bleeding into the peritoneal, pleural, or pericardial spaces may occur without obvious signs [4] [5]. "
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    ABSTRACT: . Clinical evaluation of patients with torso trauma is often a diagnostic challenge. Extended focused assessment with sonography for trauma (EFAST) is an emergency ultrasound scan that adds to the evaluation of intrathoracic abdominal and pericardial cavities done in FAST (focused assessment with sonography for trauma). Objective . This study compares EFAST (the index test) with the routine standard of care (SoC) investigations (the standard reference test) for torso trauma injuries. Methods . A cross-sectional descriptive study was conducted over a 3-month period. Eligible patients underwent EFAST scanning and the SoC assessment. The diagnostic accuracy of EFAST was calculated using sensitivity and specificity scores. Results . We recruited 197 patients; the M : F ratio was 5 : 1, with mean age of 27 years (SD 11). The sensitivity of EFAST was 100%, the specificity was 97%, the PPV was 87%, and the NPV was 100%. It took 5 minutes on average to complete an EFAST scan. 168 (85%) patients were EFAST-scanned. Most patients (82) (48%) were discharged on the same day of hospitalization, while 7 (4%) were still at the hospital after two weeks. The mortality rate was 18 (9%). Conclusion . EFAST is a reliable method of diagnosing torso injuries in a resource limited context.
    Full-text · Article · Jul 2014 · International Journal of Emergency Medicine
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    • "Hemorrhage may occur due to direct injury, and is frequently complicated by coagulopathy [2,3]. Post-injury coagulopathy may exacerbate hemorrhage and contribute to poor outcome and an increased transfusion requirement [4,5]. "
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    ABSTRACT: The optimal transfusion protocol remains unknown in the trauma setting. This retrospective cohort study aimed to determine if goal-directed transfusion protocol based on standard thrombelastography (TEG) is feasible and beneficial in patients with abdominal trauma. Sixty adult patients with abdominal trauma who received 2 or more units of red blood cell transfusion within 24 hours of admission were studied. Patients managed with goal-directed transfusion protocol via TEG (goal-directed group) were compared to patients admitted before utilization of the protocol (control group). There were 29 patients in the goal-directed group and 31 in the control group. Baseline parameters were similar except for higher admission systolic blood pressure in the goal-directed group than the control group (121.8 +/- 23.1 mmHg vs 102.7 +/- 26.5 mmHg, p < 0.01). At 24 h, patients in the goal-directed group had shorter aPTT compared to patients in the control group (39.2 +/- 16.3 s vs 58.6 +/- 36.6 s, p = 0.044). Administration of total blood products at 24 h appeared to be fewer in the goal-directed group than the control group (10.2 [7.0-43.1]U vs 14.8 [8.3-37.6]U, p = 0.28), but this was not statistically significant. Subgroup analysis including patients with ISS >=16 showed that patients in the goal-directed group had significantly fewer consumption of total blood products than patients in the control group (7[6.1, 47.0]U vs 37.6[14.5, 89.9]U, p = 0.015). No differences were found in mortality at 28d, length of stay in intensive care unit and hospital between the two groups. Goal-directed transfusion protocol via standard TEG was achievable in patients with abdominal trauma. The novel protocol, compared to conventional transfusion management, has the potential to decrease blood product utilization and prevent exacerbation of coagulation function.
    Full-text · Article · Apr 2014 · World Journal of Emergency Surgery
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