Clinical and mechanistic drivers of acute traumatic coagulopathy

Mitchell Jay Cohen, Matt Kutcher, Britt Redick, Mary Nelson, Mariah Call, Margaret Knudson, Martin A. Schreiber, Eileen M. Bulger, Peter Muskat, Louis H. Alarcon, John G Myers, Mohammad H. Rahbar, Karen J. Brasel, Herb A. Phelan, Deborah J. Del Junco, Erin E. Fox, Charles E. Wade, John B. Holcomb, Bryan A. Cotton, Nena Matijevic

Research output: Contribution to journalArticle

99 Citations (Scopus)

Abstract

BACKGROUND: Acute traumatic coagulopathy (ATC) occurs after severe injury and shock and is associated with increased bleeding, morbidity, and mortality. The effects of ATC and hemostatic resuscitation on outcome are not well-explored. The PRospective Observational Multicenter Major Trauma Transfusion (PROMMTT) study provided a unique opportunity to characterize coagulation and the effects of resuscitation on ATC after severe trauma. METHODS: Blood samples were collected upon arrival on a subset of PROMMTT patients. Plasma clotting factor levels were prospectively assayed for coagulation factors. These data were analyzed with comprehensive PROMMTT clinical data. RESULTS: There were 1,198 patients with laboratory results, of whom 41.6% were coagulopathic. Using international normalized ratio of 1.3 or greater, 41.6% of patients (448) were coagulopathic, while 20.5% (214) were coagulopathic using partial thromboplastin time of 35 or greater. Coagulopathy was primarily associated with a combination of an Injury Severity Score (ISS) of greater than 15 and a base deficit (BD) of less than j6 (p G 0.05). Regression modeling for international normalized ratioYbased coagulopathy shows that prehospital crystalloid (odds ratio [OR], 1.05), ISS (OR, 1.03), Glasgow Coma Scale (GCS) score (OR, 0.93), heart rate (OR, 1.08), systolic blood pressure (OR, 0.96), BD (OR, 0.92), and temperature (OR, 0.84) were significant predictors of coagulopathy (all p G 0.03). A subset of 165 patients had blood samples collected and coagulation factor analysis performed. Elevated ISS and BD were associated with elevation of aPC and depletion of factors (all p G 0.05). Reductions in factors I, II, V, VIII and an increase in aPC drive ATC (all p G 0.04). Similar results were found for partial thromboplastin timeYdefined coagulopathy. CONCLUSION: ATC is associated with the depletion of factors I, II, V, VII, VIII, IX, and X and is driven by the activation of the protein C system. These data provide additional mechanistic understanding of the drivers of coagulation abnormalities after injury. Further understanding of the drivers of ATC and the effects of resuscitation can guide factor-guided resuscitation and correction of coagulopathy after injury.

Original languageEnglish (US)
JournalJournal of Trauma and Acute Care Surgery
Volume75
Issue number1 SUPPL1
DOIs
StatePublished - 2013

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Odds Ratio
Resuscitation
Wounds and Injuries
Injury Severity Score
Blood Coagulation Factors
Fibrinogen
Blood Pressure
Glasgow Coma Scale
International Normalized Ratio
Partial Thromboplastin Time
Thromboplastin
Hemostatics
Protein C
Statistical Factor Analysis
Shock
Heart Rate
Hemorrhage
Morbidity
Temperature
Mortality

Keywords

  • Bleeding
  • Coagulation
  • Injury
  • PROMMTT
  • Trauma

ASJC Scopus subject areas

  • Critical Care and Intensive Care Medicine
  • Surgery

Cite this

Cohen, M. J., Kutcher, M., Redick, B., Nelson, M., Call, M., Knudson, M., ... Matijevic, N. (2013). Clinical and mechanistic drivers of acute traumatic coagulopathy. Journal of Trauma and Acute Care Surgery, 75(1 SUPPL1). https://doi.org/10.1097/TA.0b013e31828fa43d

Clinical and mechanistic drivers of acute traumatic coagulopathy. / Cohen, Mitchell Jay; Kutcher, Matt; Redick, Britt; Nelson, Mary; Call, Mariah; Knudson, Margaret; Schreiber, Martin A.; Bulger, Eileen M.; Muskat, Peter; Alarcon, Louis H.; Myers, John G; Rahbar, Mohammad H.; Brasel, Karen J.; Phelan, Herb A.; Del Junco, Deborah J.; Fox, Erin E.; Wade, Charles E.; Holcomb, John B.; Cotton, Bryan A.; Matijevic, Nena.

In: Journal of Trauma and Acute Care Surgery, Vol. 75, No. 1 SUPPL1, 2013.

Research output: Contribution to journalArticle

Cohen, MJ, Kutcher, M, Redick, B, Nelson, M, Call, M, Knudson, M, Schreiber, MA, Bulger, EM, Muskat, P, Alarcon, LH, Myers, JG, Rahbar, MH, Brasel, KJ, Phelan, HA, Del Junco, DJ, Fox, EE, Wade, CE, Holcomb, JB, Cotton, BA & Matijevic, N 2013, 'Clinical and mechanistic drivers of acute traumatic coagulopathy', Journal of Trauma and Acute Care Surgery, vol. 75, no. 1 SUPPL1. https://doi.org/10.1097/TA.0b013e31828fa43d
Cohen, Mitchell Jay ; Kutcher, Matt ; Redick, Britt ; Nelson, Mary ; Call, Mariah ; Knudson, Margaret ; Schreiber, Martin A. ; Bulger, Eileen M. ; Muskat, Peter ; Alarcon, Louis H. ; Myers, John G ; Rahbar, Mohammad H. ; Brasel, Karen J. ; Phelan, Herb A. ; Del Junco, Deborah J. ; Fox, Erin E. ; Wade, Charles E. ; Holcomb, John B. ; Cotton, Bryan A. ; Matijevic, Nena. / Clinical and mechanistic drivers of acute traumatic coagulopathy. In: Journal of Trauma and Acute Care Surgery. 2013 ; Vol. 75, No. 1 SUPPL1.
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abstract = "BACKGROUND: Acute traumatic coagulopathy (ATC) occurs after severe injury and shock and is associated with increased bleeding, morbidity, and mortality. The effects of ATC and hemostatic resuscitation on outcome are not well-explored. The PRospective Observational Multicenter Major Trauma Transfusion (PROMMTT) study provided a unique opportunity to characterize coagulation and the effects of resuscitation on ATC after severe trauma. METHODS: Blood samples were collected upon arrival on a subset of PROMMTT patients. Plasma clotting factor levels were prospectively assayed for coagulation factors. These data were analyzed with comprehensive PROMMTT clinical data. RESULTS: There were 1,198 patients with laboratory results, of whom 41.6{\%} were coagulopathic. Using international normalized ratio of 1.3 or greater, 41.6{\%} of patients (448) were coagulopathic, while 20.5{\%} (214) were coagulopathic using partial thromboplastin time of 35 or greater. Coagulopathy was primarily associated with a combination of an Injury Severity Score (ISS) of greater than 15 and a base deficit (BD) of less than j6 (p G 0.05). Regression modeling for international normalized ratioYbased coagulopathy shows that prehospital crystalloid (odds ratio [OR], 1.05), ISS (OR, 1.03), Glasgow Coma Scale (GCS) score (OR, 0.93), heart rate (OR, 1.08), systolic blood pressure (OR, 0.96), BD (OR, 0.92), and temperature (OR, 0.84) were significant predictors of coagulopathy (all p G 0.03). A subset of 165 patients had blood samples collected and coagulation factor analysis performed. Elevated ISS and BD were associated with elevation of aPC and depletion of factors (all p G 0.05). Reductions in factors I, II, V, VIII and an increase in aPC drive ATC (all p G 0.04). Similar results were found for partial thromboplastin timeYdefined coagulopathy. CONCLUSION: ATC is associated with the depletion of factors I, II, V, VII, VIII, IX, and X and is driven by the activation of the protein C system. These data provide additional mechanistic understanding of the drivers of coagulation abnormalities after injury. Further understanding of the drivers of ATC and the effects of resuscitation can guide factor-guided resuscitation and correction of coagulopathy after injury.",
keywords = "Bleeding, Coagulation, Injury, PROMMTT, Trauma",
author = "Cohen, {Mitchell Jay} and Matt Kutcher and Britt Redick and Mary Nelson and Mariah Call and Margaret Knudson and Schreiber, {Martin A.} and Bulger, {Eileen M.} and Peter Muskat and Alarcon, {Louis H.} and Myers, {John G} and Rahbar, {Mohammad H.} and Brasel, {Karen J.} and Phelan, {Herb A.} and {Del Junco}, {Deborah J.} and Fox, {Erin E.} and Wade, {Charles E.} and Holcomb, {John B.} and Cotton, {Bryan A.} and Nena Matijevic",
year = "2013",
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TY - JOUR

T1 - Clinical and mechanistic drivers of acute traumatic coagulopathy

AU - Cohen, Mitchell Jay

AU - Kutcher, Matt

AU - Redick, Britt

AU - Nelson, Mary

AU - Call, Mariah

AU - Knudson, Margaret

AU - Schreiber, Martin A.

AU - Bulger, Eileen M.

AU - Muskat, Peter

AU - Alarcon, Louis H.

AU - Myers, John G

AU - Rahbar, Mohammad H.

AU - Brasel, Karen J.

AU - Phelan, Herb A.

AU - Del Junco, Deborah J.

AU - Fox, Erin E.

AU - Wade, Charles E.

AU - Holcomb, John B.

AU - Cotton, Bryan A.

AU - Matijevic, Nena

PY - 2013

Y1 - 2013

N2 - BACKGROUND: Acute traumatic coagulopathy (ATC) occurs after severe injury and shock and is associated with increased bleeding, morbidity, and mortality. The effects of ATC and hemostatic resuscitation on outcome are not well-explored. The PRospective Observational Multicenter Major Trauma Transfusion (PROMMTT) study provided a unique opportunity to characterize coagulation and the effects of resuscitation on ATC after severe trauma. METHODS: Blood samples were collected upon arrival on a subset of PROMMTT patients. Plasma clotting factor levels were prospectively assayed for coagulation factors. These data were analyzed with comprehensive PROMMTT clinical data. RESULTS: There were 1,198 patients with laboratory results, of whom 41.6% were coagulopathic. Using international normalized ratio of 1.3 or greater, 41.6% of patients (448) were coagulopathic, while 20.5% (214) were coagulopathic using partial thromboplastin time of 35 or greater. Coagulopathy was primarily associated with a combination of an Injury Severity Score (ISS) of greater than 15 and a base deficit (BD) of less than j6 (p G 0.05). Regression modeling for international normalized ratioYbased coagulopathy shows that prehospital crystalloid (odds ratio [OR], 1.05), ISS (OR, 1.03), Glasgow Coma Scale (GCS) score (OR, 0.93), heart rate (OR, 1.08), systolic blood pressure (OR, 0.96), BD (OR, 0.92), and temperature (OR, 0.84) were significant predictors of coagulopathy (all p G 0.03). A subset of 165 patients had blood samples collected and coagulation factor analysis performed. Elevated ISS and BD were associated with elevation of aPC and depletion of factors (all p G 0.05). Reductions in factors I, II, V, VIII and an increase in aPC drive ATC (all p G 0.04). Similar results were found for partial thromboplastin timeYdefined coagulopathy. CONCLUSION: ATC is associated with the depletion of factors I, II, V, VII, VIII, IX, and X and is driven by the activation of the protein C system. These data provide additional mechanistic understanding of the drivers of coagulation abnormalities after injury. Further understanding of the drivers of ATC and the effects of resuscitation can guide factor-guided resuscitation and correction of coagulopathy after injury.

AB - BACKGROUND: Acute traumatic coagulopathy (ATC) occurs after severe injury and shock and is associated with increased bleeding, morbidity, and mortality. The effects of ATC and hemostatic resuscitation on outcome are not well-explored. The PRospective Observational Multicenter Major Trauma Transfusion (PROMMTT) study provided a unique opportunity to characterize coagulation and the effects of resuscitation on ATC after severe trauma. METHODS: Blood samples were collected upon arrival on a subset of PROMMTT patients. Plasma clotting factor levels were prospectively assayed for coagulation factors. These data were analyzed with comprehensive PROMMTT clinical data. RESULTS: There were 1,198 patients with laboratory results, of whom 41.6% were coagulopathic. Using international normalized ratio of 1.3 or greater, 41.6% of patients (448) were coagulopathic, while 20.5% (214) were coagulopathic using partial thromboplastin time of 35 or greater. Coagulopathy was primarily associated with a combination of an Injury Severity Score (ISS) of greater than 15 and a base deficit (BD) of less than j6 (p G 0.05). Regression modeling for international normalized ratioYbased coagulopathy shows that prehospital crystalloid (odds ratio [OR], 1.05), ISS (OR, 1.03), Glasgow Coma Scale (GCS) score (OR, 0.93), heart rate (OR, 1.08), systolic blood pressure (OR, 0.96), BD (OR, 0.92), and temperature (OR, 0.84) were significant predictors of coagulopathy (all p G 0.03). A subset of 165 patients had blood samples collected and coagulation factor analysis performed. Elevated ISS and BD were associated with elevation of aPC and depletion of factors (all p G 0.05). Reductions in factors I, II, V, VIII and an increase in aPC drive ATC (all p G 0.04). Similar results were found for partial thromboplastin timeYdefined coagulopathy. CONCLUSION: ATC is associated with the depletion of factors I, II, V, VII, VIII, IX, and X and is driven by the activation of the protein C system. These data provide additional mechanistic understanding of the drivers of coagulation abnormalities after injury. Further understanding of the drivers of ATC and the effects of resuscitation can guide factor-guided resuscitation and correction of coagulopathy after injury.

KW - Bleeding

KW - Coagulation

KW - Injury

KW - PROMMTT

KW - Trauma

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