title: High circulating adrenaline levels at admission predict increased mortality after trauma.
abstract: BACKGROUND
  Trauma-induced acute coagulopathy predicts a poor outcome. Although its pathophysiology is unclear, severe injury and shock(hypoperfusion) are proposed drivers. This study investigated the association between sympathoadrenal activation (circulating catecholamines) and biomarkers of coagulopathy.
  
  
  METHODS
  Prospective study of 75 adult trauma patients admitted to a Level I trauma center directly from the scene of accident. Patients were selected blinded post hoc from three predefined Injury Severity Score groups (<16, 16-27, and >27) and had available blood samples on arrival. We measured activated partial thromboplastin time, international normalized ratio, hematology, biochemistry, circulating adrenaline and noradrenaline, 11 biomarkers of tissue and endothelial damage, glycocalyx degradation, natural anticoagulation and fibrinolysis (histone-complexed DNA fragments, high-mobility group box 1, syndecan-1, von Willebrand factor, soluble thrombomodulin, protein C, tissue factor pathway inhibitor, antithrombin, tissue-type plasminogen activator, plasminogen activator inhibitor-1,D-dimer) and registered 30-day mortality. Biomarkers were compared between survivors and nonsurvivors.
  
  
  RESULTS
  The adrenaline level was increased in nonsurvivors (p = 0.026), it was independently associated with increased activated partial thromboplastin time (p = 0.034) and syndecan-1 (p = 0.007), a marker of glycocalyx degradation, and it correlated with biomarkers of tissue and endothelial damage (histone-complexed DNA, high-mobility group box 1, soluble thrombomodulin) and hyperfibrinolysis (tissue-type plasminogen activator, D-dimer). Furthermore, nonsurvivors had higher syndecan-1, tissue factor pathway inhibitor, and D-dimer levels (all p < 0.05). Circulating adrenaline was independently associated with 30-day mortality(OR, 5.92 [95% CI, 1.48 –23.73]; p = 0.012) together with age (p = 0.001) and severe head injury (Abbreviated Injury Scale head >3; p = 0.011).
  
  
  CONCLUSIONS
  The trauma-induced catecholamine surge is closely associated with biomarkers of tissue and endothelial damage, glycocalyx degradation,coagulopathy including hyperfibrinolysis and independently predicts mortality.
authors.affiliation: Section forTransfusion Medicine, Capital Region Blood Bank, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, Copenhagen, Denmark. per.johansson@rh.regionh.dk
authors.forename: Pär Ingemar
authors.initials: PI
authors.lastname: Johansson
authors.forename: Jakob
authors.initials: J
authors.lastname: Stensballe
authors.forename: Lars Simon
authors.initials: LS
authors.lastname: Rasmussen
authors.forename: Sisse Rye
authors.initials: SR
authors.lastname: Ostrowski
mesh_terms: D000328:Adult; D015415:Biomarkers / Q000097:blood; D016009:Chi-Square Distribution; D004247:DNA / Q000097:blood; D003718:Denmark / Q000453:epidemiology; D004797:Enzyme-Linked Immunosorbent Assay; D004837:Epinephrine / Q000097:blood*; D005260:Female; D005338:Fibrin Fibrinogen Degradation Products / Q000378:metabolism; D015600:Glasgow Coma Scale; D024002:HMGB Proteins / Q000097:blood; D006801:Humans; D015601:Injury Severity Score; D008297:Male; D008875:Middle Aged; D010314:Partial Thromboplastin Time; D011237:Predictive Value of Tests; D011446:Prospective Studies; D011863:Radioimmunoassay; D012044:Regression Analysis; D012307:Risk Factors; D018709:Statistics, Nonparametric; D053668:Syndecan-1 / Q000097:blood; D018180:Thrombomodulin / Q000097:blood; D010959:Tissue Plasminogen Activator / Q000097:blood; D014193:Trauma Centers; D014947:Wounds and Injuries / Q000097:blood* / Q000401:mortality*
chemical_list: D015415:Biomarkers; D005338:Fibrin Fibrinogen Degradation Products; D024002:HMGB Proteins; D053668:Syndecan-1; D018180:Thrombomodulin; C036309:fibrin fragment D; D004247:DNA; D010959:Tissue Plasminogen Activator; D004837:Epinephrine