Characterization of distinct coagulopathic phenotypes in injury: Pathway-specific drivers and implications for individualized treatment.
International normalized ratio (INR) and partial thromboplastin time (PTT) are used interchangeably to diagnose acute traumatic coagulopathy but reflect disparate activation pathways. In this study, we identified injury/patient characteristics and coagulation factors that drive contact pathway, tissue factor pathway (TF), and common pathway dysfunction by examining injured patients with discordant coagulopathies. We hypothesized that patients with INR/PTT discordance reflect differing phenotypes representing contact versus tissue factor pathway perturbations and that characterization will provide targets to guide individualized resuscitation.



Plasma samples were prospectively collected from 1,262 critically injured patients at a single Level I trauma center. Standard coagulation measures and an extensive panel of procoagulant and anticoagulant factors were assayed and analyzed with demographic and outcome data.



Fourteen percent of patients were coagulopathic on admission. Among these, 48% had abnormal INR and PTT (BOTH), 43% had isolated prolonged PTT (PTT-CONTACT), and 9% had isolated elevated INR (INR-TF). PTT-CONTACT and BOTH had lower Glasgow Coma Scale score than INR-TF (p < 0.001). INR-TF had decreased factor VII activity compared with PTT-CONTACT, whereas PTT-CONTACT had decreased factor VIII activity compared with INR-TF. All coagulopathic patients had factor V deficits, but activity was lowest in BOTH, suggesting an additive downstream effect of disordered activation pathways. Patients with PTT-CONTACT received half as much packed red blood cell and fresh frozen plasma as did the other groups (p < 0.001). Despite resuscitation, mortality was higher for coagulopathic patients; mortality was highest in BOTH and higher in PTT-CONTACT than in INR-TF (71%, 60%, 41%; p = 0.04).



Discordant phenotypes demonstrate differential factor deficiencies consistent with dysfunction of contact versus tissue factor pathways with additive effects from common pathway dysfunction. Recognition and treatment of pathway-specific factor deficiencies driving different coagulopathic phenotypes in injured patients may individualize resuscitation and improve outcomes.



Prognostic/epidemiological study, level II.
From the Department of Surgery (S.A.C., L.Z.K., B.M.H., A.S.C., R.C.K., M.F.N., C.M.H., C.S.C., R.A.C.), San Francisco General Hospital and the University of California, San Francisco, California; and Denver Health Medical Center and the University of Colorado (M.J.C.), Denver, Colorado.
S Ariane
SA
Christie
Lucy Z
LZ
Kornblith
Benjamin M
BM
Howard
Amanda S
AS
Conroy
Ryan C
RC
Kunitake
Mary F
MF
Nelson
Carolyn M
CM
Hendrickson
Carolyn S
CS
Calfee
Rachael A
RA
Callcut
Mitchell Jay
MJ
Cohen
D000328:Adult; D001778:Blood Coagulation Disorders / Q000097:blood / Q000175:diagnosis / Q000209:etiology* / Q000628:therapy; D001803:Blood Transfusion / Q000706:statistics & numerical data; D005167:Factor VII / Q000032:analysis; D005169:Factor VIII / Q000032:analysis; D005260:Female; D015600:Glasgow Coma Scale; D006801:Humans; D019934:International Normalized Ratio; D008297:Male; D008875:Middle Aged; D010314:Partial Thromboplastin Time; D012151:Resuscitation; D014193:Trauma Centers; D014947:Wounds and Injuries / Q000097:blood / Q000150:complications*; D055815:Young Adult
D005167:Factor VII; D005169:Factor VIII