Elsevier

Injury

Volume 38, Issue 3, March 2007, Pages 298-304
Injury

Early coagulopathy in multiple injury: An analysis from the German Trauma Registry on 8724 patients

https://doi.org/10.1016/j.injury.2006.10.003Get rights and content

Summary

Background

There is increasing evidence for acute traumatic coagulopathy occurring prior to emergency room (ER) admission but detailed information is lacking.

Patients and methods

A retrospective analysis using the German Trauma Registry database including 17,200 multiple injured patients was conducted to determine (a) to what extent clinically relevant coagulopathy has already been established upon ER admission, and whether its presence was associated (b) with the amount of intravenous fluids (i.v.) administered pre-clinically, (c) with the magnitude of injury, and (d) with impaired outcome and mortality. Eight thousand seven hundred and twenty-four patients with complete data sets were screened.

Results

Coagulopathy upon ER admission as defined by prothrombin time test (Quick's value) <70% and/or platelets <100,000 μl−1, was present in 34.2% of all patients. There was an increasing incidence for coagulopathy with increasing amounts of i.v. fluids administered pre-clinically. Coagulopathy was observed in >40% of patients with >2000 ml, in >50% with >3000 ml, and in >70% with >4000 ml administered. Ten percentage of patients presented with clotting disorders although pre-clinical resuscitation was limited to 500 ml of i.v. fluids maximum. The mean ISS score in the coagulopathy group was 30 (S.D. 15) versus 21 (S.D. 12) (p < 0.001). Twenty-nine percentage of patients with coagulopathy developed multi organ failure (p < 0.001). Early in-hospital mortality (<24 h) was 13% in patients with coagulopathy (p < 0.001) and overall in-hospital mortality totalled 28% (p < 0.001).

Conclusion

There is a high frequency of established coagulopathy in multiple injury upon ER admission. The presence of early traumatic coagulopathy was associated with the amount of intravenous fluids administered pre-clinically, magnitude of injury, and impaired outcome.

Introduction

Uncontrolled haemorrhage is responsible for more than 50% of all trauma deaths within the first 48 h after hospital admission.28 Critical bleeding together with traditional iatrogenic emergency interventions ultimately lead to hypothermia, acidosis and combined dilution and consumption coagulopathy. As each abnormality itself may substantially exacerbate the other a downward spiral is initiated rapidly accelerating to death.29 To date, only limited data exist on the incidence and extent of acute early coagulopathy even prior to hospital admission, possibly triggered by the injury itself or via release of trauma-associated mediators and aggravated by iatrogenic intervention.5, 9, 11, 13, 19, 24, 25 However, early recognition accompanied by adequate management of acute early coagulopathy would substantially reduce mortality and improve outcome in severely injured patients. The present investigation was undertaken to determine (a) to what extent clinically relevant coagulopathy has already been established upon hospital emergency room (ER) admission, and whether its presence was associated (b) with the amount of intravenous fluids administered pre-clinically, (c) with the magnitude of injury, and (d) with impaired outcome and mortality.

Section snippets

Patients and methods

A total of 17,200 data sets derived from the German Trauma Registry database1 (Traumaregister der Deutschen Gesellschaft für Unfallchirurgie/DGU-Traumaregister) of severely multiple injured patients were reviewed. Eight thousand seven hundred and twenty-four sets contained complete data on coagulation parameters and were screened for presence or absence of acute traumatic coagulopathy upon ER admission.

Results

Basic characteristics of patients with and without coagulopathy upon ER admission including main differences between both groups are summarised in Table 1. Coagulopathy upon ER admission was present in 2989 (34.2%) of all patients. Males were more affected than females (72.5% versus 27.5%) and in 96% the trauma mechanism was blunt. The mean time from injury to arrival of the patient in the emergency department was 74 (S.D. 31) min in the coagulopathy group versus 66 (S.D. 30) min in the group

Discussion

Coagulopathy upon ER admission was present in one third of patients studied. Similar frequencies have been reported previously.5, 19 To date, coagulopathy following trauma has mainly been attributed to the amount of bleeding itself and subsequently to trauma-haemorrhage associated dilution phenomena from intravenous fluid therapy, massive blood transfusion, progressive hypothermia, and acidosis.7, 18, 20, 30, 33 Similarly in the present study, the incidence for coagulopathy increased with

Conclusion

There is a high frequency of established coagulopathy in the multiply injured on ER admission. The presence of early traumatic coagulopathy was associated with the amount of intravenous fluids administered pre-clinically, magnitude of injury, and impaired outcome. These observations should be more seriously considered in the future for management and strategies to improve outcome.

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