Early coagulopathy in trauma patients: an on-scene and hospital admission study.
OBJECTIVE
Amongst trauma patients, early coagulopathy is common on hospital admission. No studies have evaluated the initial coagulation status in the pre-hospital setting. We hypothesise that the coagulopathic process begins at the time of trauma. We studied the on-scene and on hospital arrival coagulation profile of trauma patients.


METHODS
Prospective, observational study investigating the on-scene coagulation profile and its time course. We studied 45 patients at the scene of the accident, before fluid administration, and on hospital admission and classified their coagulopathy using the International Society on Thrombosis and Haemostasis score during a 2-month period. Prothrombin time, activated partial thromboplastin time, fibrinogen concentration, factors II, V and VII activity, fibrin degradation products, antithrombin and protein C activities, platelet counts and base deficit were measured.


RESULTS
The median injury severity score was 25 (13-35). On-scene, coagulation status was abnormal in 56% of patients. Protein C activities were decreased in the trauma-associated coagulopathy group (p=.02). Drops in protein C activities were associated with changes in activated partial thromboplastin time, prothrombin time, fibrinogen concentration, factor V and antithrombin activities. Only factor V levels decreased significantly with the severity of the trauma. On hospital admission, coagulation status was abnormal in 60% of patients. The on-scene coagulopathy was spontaneously normalised only in 2 patients whereas others had the same or a poorer coagulopathy status. All parameters of coagulation were significantly abnormal comparing to the on-scene phase. Decreases in protein C activities were related to the coagulation status (p<.0001) and changes in other coagulation parameters. Patients with base deficit ≤-6 mmol/L had changes in antithrombin, factor V and protein C activities but no significant coagulopathy.


CONCLUSIONS
Coagulopathy occurs very early after injury, before fluid administration, at the site of accident. Coagulation and fibrinolytic systems are activated early. The incidence of coagulopathy is high and its severity is related to the injury and not to hypoperfusion.
Département d'Anesthésie-Réanimation, Hospices Civils de Lyon, Hôpital Edouard Herriot, Lyon, France. bernard.floccard@chu-lyon.fr
Bernard
B
Floccard
Lucia
L
Rugeri
Alexandre
A
Faure
Marc
M
Saint Denis
Eileen Mary
EM
Boyle
Olivier
O
Peguet
Albrice
A
Levrat
Christian
C
Guillaume
Guillaume
G
Marcotte
Alexandre
A
Vulliez
Etienne
E
Hautin
Jean Stéphane
JS
David
Claude
C
Négrier
Bernard
B
Allaouchiche
D000328:Adult; D015415:Biomarkers / Q000097:blood; D001778:Blood Coagulation Disorders / Q000097:blood / Q000175:diagnosis* / Q000453:epidemiology* / Q000209:etiology; D004632:Emergency Medical Services / Q000706:statistics & numerical data; D005260:Female; D005340:Fibrinogen / Q000378:metabolism; D006801:Humans; D015994:Incidence; D015601:Injury Severity Score; D008297:Male; D008875:Middle Aged; D010314:Partial Thromboplastin Time; D010343:Patient Admission / Q000706:statistics & numerical data*; D011237:Predictive Value of Tests; D011446:Prospective Studies; D011486:Protein C / Q000378:metabolism; D011517:Prothrombin Time; D013997:Time Factors; D014193:Trauma Centers; D014947:Wounds and Injuries / Q000097:blood / Q000150:complications* / Q000453:epidemiology*
D015415:Biomarkers; D011486:Protein C; D005340:Fibrinogen