title: Prevalence, predictors and outcome of hypofibrinogenaemia in trauma: a multicentre observational study.
abstract: BACKGROUND
  Exsanguination due to trauma-induced coagulopathy is a continuing challenge in emergency trauma care. Fibrinogen is a crucial factor for haemostatic competence, and may be the factor that reaches critically low levels first. Early fibrinogen substitution is advocated by a number of authors. Little evidence exists regarding the indications for fibrinogen supplementation in the acute phase. This study aims to estimate the prevalence of hypofibrinogenaemia in a multi-center trauma population, and to explore how initial fibrinogen concentration relates to outcome. Also, factors contributing to low fibrinogen levels are identified.
  
  
  METHODS
  Patients arriving in hospital less than 180 minutes post-injury requiring full trauma team activation in four different centers were included in the study. Time from injury, patient demographics, injury severity scores (ISS) and 28 days outcome status were recorded. Initial blood samples for coagulation and blood gas were analyzed. Generalized additive regression, piecewise linear regression, and multiple linear regression models were used for data analyses.
  
  
  RESULTS
  Out of 1,133 patients we identified a fibrinogen concentration ≤1.5g/L in 8.2%, and <2 g/L in 19.2%. A non-linear relationship between fibrinogen concentration and mortality was detected in the generalized additive and piecewise linear regression models. In the piecewise linear regression model we identified a breakpoint for optimal fibrinogen concentration at 2.29 g/L (95% confidence interval (CI): 1.93 to 2.64). Below this value the odds of death by 28 days was reduced by a factor of 0.08 (95% CI: 0.03 to 0.20) for every unit increase in fibrinogen concentration. Low age, male gender, lengthened time from injury, low base excess and high ISS were unique contributors to low fibrinogen concentrations on arrival.
  
  
  CONCLUSIONS
  Hypofibrinogenaemia is common in trauma and strongly associated with poor outcome. Below an estimated critical fibrinogen concentration value of 2.29 g/L a dramatic increase in mortality was detected. This finding indicates that the negative impact of low fibrinogen concentrations may have been previously underestimated. A number of clinically identifiable factors are associated with hypofibrinogenaemia. They should be considered in the management of massively bleeding patients. Interventional trials with fibrinogen substitution in high-risk patients need to be undertaken.
authors.forename: Jostein S
authors.initials: JS
authors.lastname: Hagemo
authors.forename: Simon
authors.initials: S
authors.lastname: Stanworth
authors.forename: Nicole P
authors.initials: NP
authors.lastname: Juffermans
authors.forename: Karim
authors.initials: K
authors.lastname: Brohi
authors.forename: Mitchell
authors.initials: M
authors.lastname: Cohen
authors.forename: Pär I
authors.initials: PI
authors.lastname: Johansson
authors.forename: Jo
authors.initials: J
authors.lastname: Røislien
authors.forename: Torsten
authors.initials: T
authors.lastname: Eken
authors.forename: Paal A
authors.initials: PA
authors.lastname: Næss
authors.forename: Christine
authors.initials: C
authors.lastname: Gaarder
mesh_terms: D000328:Adult; D000347:Afibrinogenemia / Q000151:congenital* / Q000175:diagnosis / Q000453:epidemiology / Q000628:therapy; D004638:Emergency Treatment / Q000639:trends; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D011237:Predictive Value of Tests; D015995:Prevalence; D011446:Prospective Studies; D012189:Retrospective Studies; D014947:Wounds and Injuries / Q000175:diagnosis* / Q000453:epidemiology* / Q000628:therapy; D055815:Young Adult