title: Revisiting early postinjury mortality: are they bleeding because they are dying or dying because they are bleeding?
abstract: BACKGROUND
  Intense debate continues in the search of the optimal ratio of blood components to deliver preemptively in the critically injured patient anticipated to require a massive transfusion. A major challenge is distinguishing patients with refractory coagulopathy versus those with overwhelming injuries who will perish irrespective of blood component administration. The hypothesis of this clinical study is that a predominant number of early deaths from hemorrhage are irretrievable despite an aggressive transfusion policy.
  
  
  METHODS
  During the 7-y period ending in December 2009, there were 772 in-hospital trauma deaths. Each of these deaths had been assigned a cause of death via concurrent review by the multidisciplinary hospital trauma quality improvement committee. Emergency department deaths and patients arriving from outside facilities were excluded from this study.
  
  
  RESULTS
  Of the 382 patients (49.5% of total) who died secondary to acute blood loss, 84 (22.0%) survived beyond the ED; of these 84, 68 (81%) were male, mean age was 31 y, and 30 (36%) sustained blunt trauma. Cause of death was determined to be exsanguination in 63 (75%), coagulopathy in 13 (15%), metabolic failure in 5 (6%), and indeterminate in 3 patients (4%).
  
  
  CONCLUSIONS
  These data indicate that 75% of patients who succumb to postinjury acute blood loss are bleeding because they are dying rather than dying because they are bleeding. Conversely, only 13 (2%) of the hospital deaths were attributed to refractory coagulopathy. These critical facts need to be considered in designing studies to determine optimal massive transfusion protocols.
authors.affiliation: University of Colorado School of Medicine, Aurora, Colorado, USA.
authors.forename: Alexander P
authors.initials: AP
authors.lastname: Morton
authors.forename: Ernest E
authors.initials: EE
authors.lastname: Moore
authors.forename: Max V
authors.initials: MV
authors.lastname: Wohlauer
authors.forename: Karen
authors.initials: K
authors.lastname: Lo
authors.forename: Chris C
authors.initials: CC
authors.lastname: Silliman
authors.forename: Clay Cothren
authors.initials: CC
authors.lastname: Burlew
authors.forename: Ani
authors.initials: A
authors.lastname: Banerjee
mesh_terms: D000328:Adult; D001778:Blood Coagulation Disorders / Q000209:etiology* / Q000401:mortality* / Q000628:therapy; D016913:Blood Component Transfusion; D001803:Blood Transfusion; D015331:Cohort Studies; D003120:Colorado; D058734:Exsanguination / Q000209:etiology* / Q000401:mortality* / Q000628:therapy; D005260:Female; D017052:Hospital Mortality / Q000639:trends*; D006801:Humans; D008297:Male; D012189:Retrospective Studies; D014193:Trauma Centers; D014947:Wounds and Injuries / Q000150:complications*