Elsevier

Surgery

Volume 165, Issue 6, June 2019, Pages 1108-1115
Surgery

Trauma/Critical Care
Presented at the Academic Surgical Congress 2019
Higher mortality in pediatric and adult trauma patients with traumatic coagulopathy, using age-adjusted diagnostic criteria

Presented at the 2019 SUS/AAS Annual Surgical Congress.
https://doi.org/10.1016/j.surg.2019.03.003Get rights and content

Abstract

Background

Acute traumatic coagulopathy has been described in adult trauma patients. Acute traumatic coagulopathy may be associated with higher mortality and morbidity in pediatric trauma patients. We aimed to (1) compare acute traumatic coagulopathy incidence among various age groups, using age-adjusted normal reference values for three tests of coagulation, and (2) compare acute traumatic coagulopathy–associated mortality by age.

Methods

We queried our institutional trauma database for all level 1 and 2 activations with an injury severity score ≥ 9 during 2012 to 2017. Demographics, injury information, and coagulation test results were collected. Coagulopathy was defined using published age-specific and assay-specific parameters. Variables were compared among age groups (children, adults, and older adults), and logistic regression was used to determine independent associations with mortality.

Results

A total of 1,983 patients were included with a median injury severity score of 17 and mortality of 12%. Prolonged partial thromboplastin time, prolonged international normalized ratio, and hypofibrinogenemia were all strongly associated with mortality among adults and children, but not among older adults (P < .001, P < .001, and P > .01, respectively). Logistic regression revealed an independent association between prolonged partial thromboplastin time and mortality (P < .001).

Conclusion

Prolonged partial thromboplastin time/international normalized ratio and hypofibrinogenemia were common among trauma patients of all ages and were associated with mortality among children and adults, but not older adults, perhaps implicating age-related hemostatic biologic differences.

Introduction

Traumatic injury is a major cause of disability and mortality among all ages and is the leading killer of children and young adults.1 Although coagulation derangements after traumatic injury have been appreciated for decades, only recently has traumatic (or trauma-induced) coagulopathy been characterized definitively among adults. The pathophysiology is likely multifactorial, with contributions from crystalloid dilution, hypothermia, and intravascular consumption of coagulation factors, among others.2 However, after controlling for exogenous factors, it appears that ATC persists, suggesting that ATC may be attributed in part to the injury itself and subsequent early immune and hemostatic responses.3 This is further supported by the findings that mild isolated traumatic brain injuries without major hemorrhage or shock may result in anomalies on coagulation tests immediately after injury.4

Different definitions of ATC have been explored in the literature. The majority of published reports rely on prolongation of the conventional coagulation tests on arrival to the emergency department. The most commonly used tests are the international normalized ratio (INR) calculated from prothrombin time (PT) and, to a lesser extent, partial thromboplastin time (PTT). Benefits of using these tests include their ubiquitous use among trauma centers and more than a half century of published experience with their use. Furthermore, such experience has led to a robust set of reports on the normal values among children, which differ from adults considerably, owing to normal hemostatic development in the quantity and function of both plasma procoagulant and regulatory factors, which should be considered when interpreting their results.5, 6

Recent investigations have also reported experiences with the viscoelastic hemostatic assays (ie, thromboelastography and rotational thromboelastometry), which theoretically provide a more rapid and complete picture of hemostasis and thrombotic potential and information about fibrinolysis in the traumatic setting.7 Some studies have found a relationship between clot strength and early hemorrhage that supports the utility of these devices in the evaluation and resuscitation of acutely injured patients, although a recent Cochrane review of adult trauma patients concluded that more study is required.8, 9

Therefore, it appears that the conventional coagulation tests will continue to play an important role in the diagnosis and management of ATC among patients of all ages. Despite the robust literature on ATC in adult patients, there are few published reports of the phenomenon and its consequences among children. These studies have not considered age-specific normal thresholds of coagulation tests in defining ATC. In the current study, we aimed to use age-adjusted reference values for conventional coagulation tests to investigate variations in the incidence of ATC by age and the association between ATC and mortality among each age group.

Section snippets

Patients and Methods

At our institution (Duke University Medical Center, Durham, NC), level 1 and 2 trauma codes are typically activated before patient arrival in response to prehospital vital sign or Glasgow Coma Score derangements. We queried our institutional trauma database for all level 1 and 2 trauma team activations for a 5-year period, spanning from January 1, 2013, through and including December 31, 2017, with an injury severity score (ISS) of 9 or greater to capture only those patients with moderate or

Results

A total of 1,983 subjects who presented as level 1 or 2 trauma alerts with ISS ≥ 9 had complete demographics and injury data and were included in the analysis (100%). There were 156 patients under 14 years of age (7.9% of the sample overall) and 303 older adults 65 years of age or older (15.3% of the sample overall) with a median sample age of 36 years (Table II). Overall ISS was 17 and mortality in the sample was 11.9%, making the sample generally representative of a severely injured cohort.

Discussion

ATC is an often-described and often-encountered entity among severely injured adult patients.13 Multiple definitions have been suggested, and its prevalence and consequences in the realm of pediatric trauma have only recently been queried.14, 15 The myriad definitions and associated clinical manifestations (which include hemorrhage, thrombosis, and death) have led to numerous hypotheses about its underlying mechanisms. In addition to exogenous influences from resuscitation and shock, the

Disclosure

The authors report no proprietary or commercial interest in any product mentioned or concept discussed in this article.

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