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Early coagulopathy at hospital admission predicts initial or delayed fibrinogen deficit in severe trauma patients

Deras, Pauline MD; Villiet, Maxime PharmD; Manzanera, Jonathan MD; Latry, Pascal MD; Schved, Jean-François MD, PhD; Capdevila, Xavier MD, PhD; Charbit, Jonathan MD

Journal of Trauma and Acute Care Surgery: September 2014 - Volume 77 - Issue 3 - p 433–440
doi: 10.1097/TA.0000000000000314
Original Articles
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BACKGROUND Early detection of a fibrinogen deficit in the initial phase of trauma is a determinant for anticipating massive blood loss. Hemostatic impairment should rationally be associated with an overall depletion of clotting factors, leading to early coagulopathy. The main objective of this study was to evaluate whether the severity of coagulopathy at admission could predict an initial and delayed fibrinogen deficit during the initial management of severe trauma patients.

METHODS All severe trauma patients admitted consecutively to our trauma center between January 2006 and December 2009 were retrospectively reviewed. The results of coagulation tests and plasma fibrinogen levels at admission were studied. Patients were grouped according to severity of coagulopathy at admission: prothrombin time ratio and/or activated partial thromboplastin time ratio of 1.50 or greater, between 1.49 and 1.20, or less than 1.20. Correlation between severity of coagulopathy at admission and initial or delayed fibrinogen deficit (fibrinogen level < 1.5 g/L) within the first 24 hours was established.

RESULTS Of the 663 patients studied, 481 (72%) were male, and the mean (SD) Injury Severity Score (ISS) was 21.3 (17.6). At admission, 105 patients (20%) had severe coagulopathy, 215 (33%) had moderate coagulopathy, and 313 (47%) had no coagulopathy. The number of patients with a fibrinogen level less than 1.5 g/L at admission increased with the severity of coagulopathy: 87%, 29%, and 1%, respectively (p < 0.001). Corresponding rates for an initial fibrinogen level less than 1.0 g/L were 53%, 2%, 0.3%, respectively (p < 0.001). Moreover, severity of coagulopathy at admission was an independent risk factor of the occurrence of fibrinogen deficit within the first 24 hours (p < 0.001).

CONCLUSION Early coagulopathy at admission in severe trauma patients was strongly associated with a fibrinogen deficit during initial management. In the absence of specific monitoring of fibrinogen, coagulopathy severity helps to guide fibrinogen replacement therapy.

LEVEL OF EVIDENCE Prognostic and epidemiologic study, level III.

From the Trauma Intensive Care Unit and Level 1 Regional Trauma Center (P.D., J.M., X.C., J.C.), Department of Pharmacy (M.V.), Lapeyronie University Hospital; Department of Hemovigilance and Transfusion (P.L.), Lapeyronie University Hospital; Department of Biological Hematology (J.-F.S.), Saint Eloi University Hospital; and Institut National de la Santé et de la Recherche Médicale (X.C.), Equipe INSERM U1046, Montpellier, F-34295 Cedex 5, France.

Submitted: December 24, 2013, Revised: April 14, 2014, Accepted: April 21, 2014.

Address for reprints: Pauline Deras, MD, Trauma Intensive Care Unit, Level 1 Regional Trauma Center, Lapeyronie University Hospital, 371 avenue du Doyen Gaston Giraud, 34295 Montpellier, France; email: p-deras@chu-montpellier.fr.

© 2014 Lippincott Williams & Wilkins, Inc.