title: Disseminated intravascular coagulation or acute coagulopathy of trauma shock early after trauma? An observational study.
abstract: BACKGROUND
  It is debated whether early trauma-induced coagulopathy (TIC) in severely injured patients reflects disseminated intravascular coagulation (DIC) with a fibrinolytic phenotype, acute coagulopathy of trauma shock (ACoTS) or yet other entities. This study investigated the prevalence of overt DIC and ACoTS in trauma patients and characterized these conditions based on their biomarker profiles.
  
  
  METHODS
  An observational study was carried out at a single Level I Trauma Center. Eighty adult trauma patients (≥18 years) who met criteria for full trauma team activation and had an arterial cannula inserted were included. Blood was sampled a median of 68 minutes (IQR 48 to 88) post-injury. Data on demography, biochemistry, injury severity score (ISS) and mortality were recorded. Plasma/serum was analyzed for biomarkers reflecting tissue/endothelial cell/glycocalyx damage (histone-complexed DNA fragments, Annexin V, thrombomodulin, syndecan-1), coagulation activation/inhibition (prothrombinfragment 1+2, thrombin/antithrombin-complexes, antithrombin, protein C, activated protein C, endothelial protein C receptor, protein S, tissue factor pathway inhibitor, vWF), factor consumption (fibrinogen, FXIII), fibrinolysis (D-dimer, tissue-type plasminogen activator, plasminogen activator inhibitor-1) and inflammation (interleukin (IL)-6, terminal complement complex (sC5b-9)). Comparison of patients stratified according to the presence or absence of overt DIC (International Society of Thrombosis and Hemostasis (ISTH) criteria) or ACoTS (activated partial thromboplastin time (APTT) and/or international normalized ratio (INR) above normal reference).
  
  
  RESULTS
  No patients had overt DIC whereas 15% had ACoTS. ACoTS patients had higher ISS, transfusion requirements and mortality (all P < 0.01) and a biomarker profile suggestive of enhanced tissue, endothelial cell and glycocalyx damage and consumption coagulopathy with low protein C, antithrombin, fibrinogen and FXIII levels, hyperfibrinolysis and inflammation (all P < 0.05). Importantly, in non-ACoTS patients, apart from APTT/INR, higher ISS correlated with biomarkers of enhanced tissue, endothelial cell and glycocalyx damage, protein C activation, coagulation factor consumption, hyperfibrinolysis and inflammation, that is, resembling that observed in patients with ACoTS.
  
  
  CONCLUSIONS
  ACoTS and non-ACoTS may represent a continuum of coagulopathy reflecting a progressive early evolutionarily adapted hemostatic response to the trauma hit and both are parts of TIC whereas DIC does not appear to be part of this early response.
authors.affiliation: Section for Transfusion Medicine, Capital Region Blood Bank, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, DK-2100 Copenhagen, Denmark. per.johansson@rh.regionh.dk
authors.forename: Pär I
authors.initials: PI
authors.lastname: Johansson
authors.forename: Anne Marie
authors.initials: AM
authors.lastname: Sørensen
authors.forename: Anders
authors.initials: A
authors.lastname: Perner
authors.forename: Karen Lise
authors.initials: KL
authors.lastname: Welling
authors.forename: Michael
authors.initials: M
authors.lastname: Wanscher
authors.forename: Claus F
authors.initials: CF
authors.lastname: Larsen
authors.forename: Sisse R
authors.initials: SR
authors.lastname: Ostrowski
mesh_terms: D000328:Adult; D017304:Annexin A5 / Q000097:blood; D015415:Biomarkers / Q000097:blood; D001778:Blood Coagulation Disorders / Q000097:blood / Q000209:etiology*; D015331:Cohort Studies; D004211:Disseminated Intravascular Coagulation / Q000097:blood / Q000209:etiology*; D004797:Enzyme-Linked Immunosorbent Assay; D005176:Factor XIII / Q000032:analysis; D005260:Female; D005338:Fibrin Fibrinogen Degradation Products / Q000032:analysis; D005340:Fibrinogen / Q000032:analysis; D006801:Humans; D015601:Injury Severity Score; D015850:Interleukin-6 / Q000097:blood; D008297:Male; D008875:Middle Aged; D011486:Protein C / Q000032:analysis; D012774:Shock, Traumatic / Q000097:blood / Q000150:complications*; D014193:Trauma Centers
chemical_list: D017304:Annexin A5; D015415:Biomarkers; D005338:Fibrin Fibrinogen Degradation Products; D015850:Interleukin-6; D011486:Protein C; C036309:fibrin fragment D; D005340:Fibrinogen; D005176:Factor XIII
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