title: Clot Formation Is Associated With Fibrinogen and Platelet Forces in a Cohort of Severely Injured Emergency Department Trauma Patients.
abstract: BACKGROUND
  Anticoagulation, fibrinogen consumption, fibrinolytic activation, and platelet dysfunction all interact to produce different clot formation responses after trauma. However, the relative contributions of these coagulation components to overall clot formation remain poorly defined. We examined for sources of heterogeneity in clot formation responses after trauma.
  
  
  METHODS
  Blood was sampled in the emergency department from patients meeting trauma team activation criteria at an urban trauma center. Plasma prothrombin time of 18 s or longer was used to define traumatic coagulopathy. Mean kaolin-activated thrombelastography (TEG) parameters were calculated and tested for heterogeneity using analysis of means. Discriminant analysis and forward stepwise variable selection with linear regression were used to determine if prothrombin time, fibrinogen, platelet contractile force (PCF), and D-dimer concentration, representing key mechanistic components of coagulopathy, each contribute to heterogeneous TEG responses after trauma.
  
  
  RESULTS
  Of 95 subjects, 16% met criteria for coagulopathy. Coagulopathic subjects were more severely injured with greater shock and received more blood products in the first 8 h compared with noncoagulopathic subjects. Mean (SD) TEG maximal amplitude (MA) was significantly decreased in the coagulopathic group (57.5 [SD, 4.7] mm vs. 62.7 [SD, 4.7], t test P < 0.001). The MA also exceeded the ANOM predicted upper decision limit for the noncoagulopathic group and the lower decision limit for the coagulopathic group at α = 0.05, suggesting significant heterogeneity from the overall cohort mean. Fibrinogen and PCF best discriminated TEG MA using discriminant analysis. Fibrinogen, PCF, and D-dimer were primary covariates for TEG MA using regression analysis.
  
  
  CONCLUSIONS
  Heterogeneity in TEG-based clot formation in emergency department trauma patients was linked to changes in MA. Individual parameters representing fibrin polymerization, PCFs, and fibrinolysis were primarily associated with TEG MA after trauma and should be the focus of early hemostatic therapies.
authors: *Division of Emergency Medicine, University of Washington, and Puget Sound Blood Center Research Institute, Seattle, WA; †Coagulation Advancement Laboratory, Department of Pharmacotherapy & Outcomes Science, Virginia Commonwealth University, Richmond, VA; ‡Department of Clinical Pharmacy, Faculty of Pharmacy, Cairo University, Cairo, Egypt; §Pharmacotherapy & Outcomes Science and Department of Neurosurgery, Virginia Commonwealth University, Richmond, VA; ‖Department of Anesthesiology, Virginia Commonwealth University, Richmond, VA; ¶US Army Medical Research and Materiel Command, Fort Detrick, MD; #Michigan Center for Integrative Research in Critical Care, University of Michigan, Ann Arbor, Michigan.
authors: Nathan J
authors: NJ
authors: White
authors: Jason C
authors: JC
authors: Newton
authors: Erika J
authors: EJ
authors: Martin
authors: Bassem M
authors: BM
authors: Mohammed
authors: Daniel
authors: D
authors: Contaifer
authors: Jessica L
authors: JL
authors: Bostic
authors: Gretchen M
authors: GM
authors: Brophy
authors: Bruce D
authors: BD
authors: Spiess
authors: Anthony E
authors: AE
authors: Pusateri
authors: Kevin R
authors: KR
authors: Ward
authors: Donald F
authors: DF
authors: Brophy
mesh_terms: D000328:Adult; D001777:Blood Coagulation; D001780:Blood Coagulation Tests; D001792:Blood Platelets / Q000166:cytology*; D003430:Cross-Sectional Studies; D016002:Discriminant Analysis; D004635:Emergency Medicine; D004636:Emergency Service, Hospital; D005338:Fibrin Fibrinogen Degradation Products / Q000737:chemistry; D005340:Fibrinogen / Q000737:chemistry*; D006801:Humans; D007616:Kaolin / Q000737:chemistry; D008875:Middle Aged; D011446:Prospective Studies; D011517:Prothrombin Time; D012044:Regression Analysis; D013916:Thrombelastography; D013997:Time Factors; D014947:Wounds and Injuries / Q000097:blood* / Q000628:therapy; D055815:Young Adult
chemical_list: D005338:Fibrin Fibrinogen Degradation Products; C036309:fibrin fragment D; D007616:Kaolin; D005340:Fibrinogen
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