title: Disseminated intravascular coagulopathy in the first 24 hours after trauma: the association between ISTH score and anatomopathologic evidence.
abstract: BACKGROUND
  Recent studies questioned "classical" concepts in trauma care, including whether disseminated intravascular coagulation (DIC) occurs in trauma. The knowledge on trauma DIC is limited to few studies built on diagnosing DIC with laboratory-based scores. This study explores whether DIC diagnosed by the well-established ISTH (International Society for Thrombosis and Hemostasis) score is corroborated by anatomopathologic findings.
  
  
  METHODS
  Prospective observational cohort study of severely injured (ISS ≥ 16) patients. DIC was diagnosed by the ISTH score throughout the first 24 hours after trauma. All organs surgically removed within 24 hours of trauma were reviewed by two independent pathologists. All autopsy reports were reviewed.
  
  
  RESULTS
  Of 423 patients enrolled, ∼11% had "overt DIC" and 85% had "suggestive of non-overt DIC" scores throughout the 24 hours after trauma. "Overt DIC" patients had higher mortality and worse bleeding, receiving more blood and plasma transfusions. One hundred and sixteen patients underwent surgery within 24 hours of trauma, and all 40 excised organs were reviewed by two pathologists. Twenty-seven autopsies reports were reviewed. No anatomopathologic evidence of DIC was identified in the first 24 hours, even after additional histochemical staining. d-dimer was universally elevated after trauma. Common DIC features: platelet count, fibrinogen, clotting time, and factor VIII drop were mostly absent.
  
  
  CONCLUSIONS
  d-dimer has a disproportional participation in trauma DIC scores. Within 24 hours of trauma, most severely injured patients have DIC scores "suggestive for" or of "overt DIC" but no anatomopathologic evidence of DIC. Considering pathologic findings as the gold standard diagnosis, then DIC is exceptionally uncommon and the ISTH score should not be used for trauma.
authors.affiliation: Tory Trauma Centre, Department of Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada. sandro.rizoli@sunnybrook.ca
authors.forename: Sandro
authors.initials: S
authors.lastname: Rizoli
authors.forename: Bartolomeu
authors.initials: B
authors.lastname: Nascimento
authors.forename: Nigel
authors.initials: N
authors.lastname: Key
authors.forename: Homer C
authors.initials: HC
authors.lastname: Tien
authors.forename: Sergio
authors.initials: S
authors.lastname: Muraca
authors.forename: Ruxandra
authors.initials: R
authors.lastname: Pinto
authors.forename: Mahmoud
authors.initials: M
authors.lastname: Khalifa
authors.forename: Anna
authors.initials: A
authors.lastname: Plotkin
authors.forename: Jeannie
authors.initials: J
authors.lastname: Callum
mesh_terms: D000328:Adult; D001344:Autopsy; D001777:Blood Coagulation; D001780:Blood Coagulation Tests; D002423:Cause of Death; D004211:Disseminated Intravascular Coagulation / Q000097:blood / Q000209:etiology / Q000473:pathology*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D009864:Ontario / Q000453:epidemiology; D011446:Prospective Studies; D015996:Survival Rate; D013997:Time Factors; D014947:Wounds and Injuries / Q000150:complications* / Q000175:diagnosis / Q000401:mortality