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 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 & 3 others Jacob Steinmetz, Charles E. Wade, John B. Holcomb

    Research output: Contribution to journalArticle

    5 Citations (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. (Surgery 2017;160:XXX-XXX.).

    Original languageEnglish (US)
    JournalSurgery (United States)
    DOIs
    StateAccepted/In press - Jan 1 2017

    Fingerprint

    Thrombelastography
    Aircraft
    Resuscitation
    International Normalized Ratio
    Hemorrhage
    Blood Coagulation Factors
    Mortality
    Trauma Centers
    Wounds and Injuries
    Sutures
    Observational Studies
    Blood Platelets
    Prospective Studies
    Incidence

    ASJC Scopus subject areas

    • Surgery

    Cite this

    Abnormalities of laboratory coagulation tests versus clinically evident coagulopathic bleeding : Results from the prehospital resuscitation on helicopters study (PROHS). / Chang, Ronald; Fox, Erin E.; Greene, Thomas J.; Swartz, Michael D.; DeSantis, Stacia M.; Stein, Deborah M.; Bulger, Eileen M.; Melton, Sherry M.; Goodman, Michael D.; Schreiber, Martin; Zielinski, Martin D.; O'Keeffe, Terence; Inaba, Kenji; Tomasek, Jeffrey S.; Podbielski, Jeanette M.; Appana, Savitri; Yi, Misung; Johansson, Pär I.; Henriksen, Hanne H.; Stensballe, Jakob; Steinmetz, Jacob; Wade, Charles E.; Holcomb, John B.

    In: Surgery (United States), 01.01.2017.

    Research output: Contribution to journalArticle

    Chang, R, Fox, EE, Greene, TJ, Swartz, MD, DeSantis, SM, Stein, DM, Bulger, EM, Melton, SM, Goodman, MD, Schreiber, M, 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 2017, 'Abnormalities of laboratory coagulation tests versus clinically evident coagulopathic bleeding: Results from the prehospital resuscitation on helicopters study (PROHS)', Surgery (United States). https://doi.org/10.1016/j.surg.2017.10.050
    Chang, Ronald ; Fox, Erin E. ; Greene, Thomas J. ; Swartz, Michael D. ; DeSantis, Stacia M. ; Stein, Deborah M. ; Bulger, Eileen M. ; Melton, Sherry M. ; Goodman, Michael D. ; Schreiber, Martin ; Zielinski, Martin D. ; O'Keeffe, Terence ; Inaba, Kenji ; Tomasek, Jeffrey S. ; Podbielski, Jeanette M. ; Appana, Savitri ; Yi, Misung ; Johansson, Pär I. ; Henriksen, Hanne H. ; Stensballe, Jakob ; Steinmetz, Jacob ; Wade, Charles E. ; Holcomb, John B. / Abnormalities of laboratory coagulation tests versus clinically evident coagulopathic bleeding : Results from the prehospital resuscitation on helicopters study (PROHS). In: Surgery (United States). 2017.
    @article{2627ec6ecc3847b09436c7f9f6261ffe,
    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. (Surgery 2017;160:XXX-XXX.).",
    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 Martin Schreiber 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.}",
    year = "2017",
    month = "1",
    day = "1",
    doi = "10.1016/j.surg.2017.10.050",
    language = "English (US)",
    journal = "Surgery (United States)",
    issn = "0039-6060",
    publisher = "Mosby Inc.",

    }

    TY - JOUR

    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

    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.

    PY - 2017/1/1

    Y1 - 2017/1/1

    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. (Surgery 2017;160:XXX-XXX.).

    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. (Surgery 2017;160:XXX-XXX.).

    UR - http://www.scopus.com/inward/record.url?scp=85039165623&partnerID=8YFLogxK

    UR - http://www.scopus.com/inward/citedby.url?scp=85039165623&partnerID=8YFLogxK

    U2 - 10.1016/j.surg.2017.10.050

    DO - 10.1016/j.surg.2017.10.050

    M3 - Article

    JO - Surgery (United States)

    JF - Surgery (United States)

    SN - 0039-6060

    ER -