title: The natural history of trauma-related coagulopathy: implications for treatment.
abstract: BACKGROUND
  Hemorrhage is a leading cause of death in trauma patients and coagulopathy is a significant contributor. Although the exact mechanisms of trauma-associated coagulopathy (TAC) are incompletely understood, hemostatic resuscitation strategies have been developed to treat TAC. Our study sought to identify which trauma patients develop TAC and the factors associated with its development, to describe the natural history of TAC, and to identify patients with TAC who may not require hemostatic resuscitation.
  
  
  METHODS
  Patients with early coagulopathy (International Normalized Ratio >1.3) who were admitted directly from the scene within 1 hour of injury were identified in our institutional trauma registry. We analyzed these data for the presence of TAC, predictors of early and delayed TAC, and evolution of TAC during the first 24 hours of admission.
  
  
  RESULTS
  Of 2,473 patients, 290 (12%) had early TAC (International Normalized Ratio >1.3) and 271 (11%) developed delayed TAC. Multivariate analysis identified female gender (odds ratio [OR] 1.25 [1.11-1.41]), lower pH (OR 0.08 [0.015-0.47]), lower hemoglobin (OR 0.96 [0.95-0.97]), lower temperature (OR 0.82 [0.70-0.95]), and blunt mechanism (OR 0.49 [0.33-0.71]) as factors significantly associated with development of early TAC. Progression of early TAC occurred in 64%, and these patients had more severe abdominal injury and received more emergency room crystalloid. Of patients with early TAC who did not receive fresh frozen plasma, only 49% developed worsening coagulopathy. Patients with isolated intracranial hemorrhage had higher rates of bleeding progression (75% vs. 20%, p < 0.005) in the presence of early TAC.
  
  
  CONCLUSIONS
  TAC may appear in an early or delayed form and its presence and progression are associated with a number of identifiable factors. Although TAC commonly progresses, it also resolves spontaneously in many patients. Further research is required to identify which patients with TAC require hemostatic treatment, although those with intracranial hemorrhages seem to warrant aggressive therapy.
authors.affiliation: Department of Surgery, Sunnybrook Health Sciences Centre and University of Toronto, Toronto, Canada. pengels@ualberta.ca
authors.forename: Paul T
authors.initials: PT
authors.lastname: Engels
authors.forename: Joao B
authors.initials: JB
authors.lastname: Rezende-Neto
authors.forename: Mohammed
authors.initials: M
authors.lastname: Al Mahroos
authors.forename: Sandro
authors.initials: S
authors.lastname: Scarpelini
authors.forename: Sandro B
authors.initials: SB
authors.lastname: Rizoli
authors.forename: Homer C
authors.initials: HC
authors.lastname: Tien
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001778:Blood Coagulation Disorders / Q000453:epidemiology / Q000209:etiology / Q000628:therapy*; D005260:Female; D005500:Follow-Up Studies; D006489:Hemostatic Techniques; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D009864:Ontario / Q000453:epidemiology; D011379:Prognosis; D012151:Resuscitation / Q000379:methods*; D012189:Retrospective Studies; D015996:Survival Rate / Q000639:trends; D015599:Trauma Severity Indices; D014947:Wounds and Injuries / Q000150:complications* / Q000175:diagnosis / Q000453:epidemiology; D055815:Young Adult