title: Clotting factor deficiency in early trauma-associated coagulopathy.
abstract: BACKGROUND
  Coagulopathic bleeding is a leading cause of in-hospital death after injury. A recently proposed transfusion strategy calls for early and aggressive frozen plasma transfusion to bleeding trauma patients, thus addressing trauma-associated coagulopathy (TAC) by transfusing clotting factors (CFs). This strategy may dramatically improve survival of bleeding trauma patients. However, other studies suggest that early TAC occurs by protein C activation and is independent of CF deficiency. This study investigated whether CF deficiency is associated with early TAC.
  
  
  METHODS
  This is a prospective observational cohort study of severely traumatized patients (Injury Severity Score ≥ 16) admitted shortly after injury, receiving minimal fluids and no prehospital blood. Blood was assayed for CF levels, thromboelastography, and routine coagulation tests. Critical CF deficiency was defined as ≤ 30% activity of any CF.
  
  
  RESULTS
  Of 110 patients, 22 (20%) had critical CF deficiency: critically low factor V level was evident in all these patients. International normalized ratio, activated prothrombin time, and, thromboelastography were abnormal in 32%, 36%, and 35%, respectively, of patients with any critically low CF. Patients with critical CF deficiency suffered more severe injuries, were more acidotic, received more blood transfusions, and showed a trend toward higher mortality (32% vs. 18%, p = 0.23). Computational modeling showed coagulopathic patients had pronounced delays and quantitative deficits in generating thrombin.
  
  
  CONCLUSIONS
  Twenty percent of all severely injured patients had critical CF deficiency on admission, particularly of factor V. The observed factor V deficit aligns with current understanding of the mechanisms underlying early TAC. Critical deficiency of factor V impairs thrombin generation and profoundly affects hemostasis.
authors.affiliation: Department of Surgery and Critical Care Medicine, Sunnybrook, Health Sciences Centre, University Toronto, Toronto, Ontario, Canada.
authors.forename: Sandro B
authors.initials: SB
authors.lastname: Rizoli
authors.forename: Sandro
authors.initials: S
authors.lastname: Scarpelini
authors.forename: Jeannie
authors.initials: J
authors.lastname: Callum
authors.forename: Bartolomeu
authors.initials: B
authors.lastname: Nascimento
authors.forename: Kenneth G
authors.initials: KG
authors.lastname: Mann
authors.forename: Ruxandra
authors.initials: R
authors.lastname: Pinto
authors.forename: Jan
authors.initials: J
authors.lastname: Jansen
authors.forename: Homer C
authors.initials: HC
authors.lastname: Tien
mesh_terms: D000328:Adult; D000368:Aged; D001777:Blood Coagulation / Q000502:physiology*; D020147:Coagulation Protein Disorders / Q000097:blood* / Q000150:complications / Q000453:epidemiology; D005260:Female; D005500:Follow-Up Studies; D006470:Hemorrhage / Q000097:blood / Q000453:epidemiology / Q000209:etiology*; D006801:Humans; D015994:Incidence; D015601:Injury Severity Score; D008297:Male; D008875:Middle Aged; D009864:Ontario / Q000453:epidemiology; D011446:Prospective Studies; D011517:Prothrombin Time; D013916:Thrombelastography; D014947:Wounds and Injuries / Q000097:blood / Q000150:complications* / Q000175:diagnosis; D055815:Young Adult
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