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 StensballeJacob Steinmetz, Charles E. Wade, John B. Holcomb

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    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
    Publication statusAccepted/In press - Jan 1 2017

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    ASJC Scopus subject areas

    • Surgery

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