Early trauma induced coagulopathy (ETIC): prevalence across the injury spectrum.
BACKGROUND
Newer studies have hypothesised about a coagulopathy that occurs early after trauma, early trauma induced coagulopathy, ETIC, and is defined by an elevated admission prothrombin time (PT). Also, referred to by some authors as acute traumatic coagulopathy, it has been most often studied in cohorts of severely injured or hypotensive patients. However, we wanted to prospectively investigate ETIC in a large all-comers cohort to confirm its prevalence across the entire spectrum of injury, to evaluate its risk pattern and to determine a possible relationship to reduced survival.


METHODS
We conducted a prospective cohort study at a Level I trauma centre from July 15, 2008 to November 15, 2009. Demographics, injury mechanism, time from injury and to hospital arrival, fluid and blood administration and vital signs were collected at hospital arrival and to the time of first blood sample collection for all patients admitted for 24h or longer. Our primary outcome was the incidence of mortality by the 28th hospital day, referred to as 28 day in-hospital mortality.


RESULTS
701 patients were included in the final study cohort. There was 75.3% male, 25.7% penetrating, with a mean age of 39 years. The overall mortality was 7.3%. ETIC occurred in 114 patients (16.3%) and was found to be independently associated with death (odds of death (per 0.10s increase in PT): 1.10, p=0.001). ETIC patients, as a group, were more severely injured, had more hypotension and head injury and used more crystalloid and blood products than non-ETIC patients. However, even mildly injured patients, who had an ISS<16, normal RTS score, and no fluid resuscitation, had an ETIC prevalence of 11.7% (11/94).


CONCLUSIONS
ETIC is an early, primary post-injury coagulopathy that occurs in 16.3% of admitted trauma patients. It is associated with an increase in mortality, even when controlling for crystalloids, vital signs, injury severity and head injury. It can also be found in approximately 11% of mildly injured patients (patients without physiological derangement or blood product administration). Therefore, further elucidation of ETIC is strategic to impacting trauma patient outcome.
Study completed while author at the Department of Surgery, Emory University School of Medicine, Atlanta, GA, United States; Karen Hospital, Department of Surgery, Nairobi, Kenya. Electronic address: janamac@outlook.com.
Jana B A
JB
MacLeod
Departments of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, GA, United States.
Anne M
AM
Winkler
Duke University, Surgical Residency, Department of Surgery, Durham, NC, United States.
Cameron C
CC
McCoy
New York Blood Center, New York, NY, United States.
Christopher D
CD
Hillyer
Departments of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, GA, United States; New York Blood Center, New York, NY, United States.
Beth H
BH
Shaz
D000328:Adult; D001778:Blood Coagulation Disorders / Q000453:epidemiology* / Q000209:etiology / Q000401:mortality / Q000628:therapy; D001803:Blood Transfusion / Q000379:methods* / Q000401:mortality; D015331:Cohort Studies; D042241:Early Diagnosis; D005260:Female; D005440:Fluid Therapy / Q000379:methods* / Q000401:mortality; D017052:Hospital Mortality; D006801:Humans; D015601:Injury Severity Score; D008297:Male; D015995:Prevalence; D011446:Prospective Studies; D012151:Resuscitation / Q000379:methods* / Q000401:mortality; D016019:Survival Analysis; D014193:Trauma Centers; D016896:Treatment Outcome; D014949:Wounds, Nonpenetrating / Q000150:complications* / Q000401:mortality / Q000628:therapy; D014950:Wounds, Penetrating / Q000150:complications* / Q000401:mortality / Q000628:therapy
Coagulopathy; Mortality; Patient outcome; Prospective cohort; Resuscitation; Trauma