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Functional definition and characterization of acute traumatic coagulopathy

Davenport, Ross BSc, MD, MRCS; Manson, Joanna MD, MRCS; De'Ath, Henry MD, MRCS; Platton, Sean MSc, CSci, FIBMS; Coates, Amy BSc; Allard, Shubha MD, FRCP, FRCPath; Hart, Daniel MD; Pearse, Rupert MD, FRCA; Pasi, K. John PhD, FRCP, FRCPath, FRCPCH; MacCallum, Peter MD, FRCP, FRCPath; Stanworth, Simon DPhil, MRCP, FRCPath; Brohi, Karim FRCA, FRCS

doi: 10.1097/CCM.0b013e3182281af5
Clinical Investigations

Objective: To identify an appropriate diagnostic tool for the early diagnosis of acute traumatic coagulopathy and validate this modality through prediction of transfusion requirements in trauma hemorrhage.

Design: Prospective observational cohort study.

Setting: Level 1 trauma center.

Patients: Adult trauma patients who met the local criteria for full trauma team activation. Exclusion criteria included emergency department arrival >2 hrs after injury, >2000 mL of intravenous fluid before emergency department arrival, or transfer from another hospital.

Interventions: None.

Measurements: Blood was collected on arrival in the emergency department and analyzed with laboratory prothrombin time, point-of-care prothrombin time, and rotational thromboelastometry. Prothrombin time ratio was calculated and acute traumatic coagulopathy defined as laboratory prothrombin time ratio >1.2. Transfusion requirements were recorded for the first 12 hrs following admission.

Main Results: Three hundred patients were included in the study. Laboratory prothrombin time results were available at a median of 78 (62–103) mins. Point-of-care prothrombin time ratio had reduced agreement with laboratory prothrombin time ratio in patients with acute traumatic coagulopathy, with 29% false-negative results. In acute traumatic coagulopathy, the rotational thromboelastometry clot amplitude at 5 mins was diminished by 42%, and this persisted throughout clot maturation. Rotational thromboelastometry clotting time was not significantly prolonged. Clot amplitude at a 5-min threshold of ≤35 mm had a detection rate of 77% for acute traumatic coagulopathy with a false-positive rate of 13%. Patients with clot amplitude at 5 mins ≤35 mm were more likely to receive red cell (46% vs. 17%, p < .001) and plasma (37% vs. 11%, p < .001) transfusions. The clot amplitude at 5 mins could identify patients who would require massive transfusion (detection rate of 71%, vs. 43% for prothrombin time ratio >1.2, p < .001).

Conclusions: In trauma hemorrhage, prothrombin time ratio is not rapidly available from the laboratory and point-of-care devices can be inaccurate. Acute traumatic coagulopathy is functionally characterized by a reduction in clot strength. With a threshold of clot amplitude at 5 mins of ≤35 mm, rotational thromboelastometry can identify acute traumatic coagulopathy at 5 mins and predict the need for massive transfusion.

From the Trauma Sciences (RD, JM, HAD, AC, KB), William Harvey Research Institute (RP), and Pathology Group (KJP), Blizard Institute of Cell and Molecular Science, Bart's and the London School of Medicine and Dentistry, Queen Mary University of London, UK; Department of Haematology (SP, SA, DH, PM), Bart's and the London NHS Trust, UK; and NHS Blood and Transplant (SS), John Radcliffe Hospital, Oxford, UK.

Supported, in part, by the National Institute for Health Research: Programme Grant for Applied Research (RP-PG-0407-10036). Rupert Pearse is a National Institute for Health Research (UK) Clinician Scientist. Pentapharm GmbH (Munich, Germany) provided ROTEM reagent and equipment on an unrestricted basis.

Dr. Davenport and Dr. Brohi received unrestricted reagent/equipment grants from ROTEM. The remaining authors have not disclosed any potential conflicts of interest.

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© 2011 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins