J. N. Luker1,2, J. D. Karalis2, S. Tejiram1,2, J. Zhang2, K. M. Johnson2, L. T. Moffatt2, M. M. McLawhorn2, J. W. Shupp1,2 1MedStar Washington Hospital Center,Burn Center, Department Of Surgery,Washington, DC, USA 2MedStar Health Research Institute,Firefighters’ Burn And Surgical Research Laboratory,Washington, DC, USA
Introduction:
Acute coagulopathy of trauma has been studied extensively in the setting of blunt and penetrating injury. Conversely, little is known about how thermal injury augments the homeostasis of coagulation. To understand how clot strength is augmented after burn injury Rapid thromboelastography was performed post-injury in a cohort of thermally injured patients. This study aimed to assess whether burn patients exhibit changes in clot strength that could be associated with occult or gross coagulopathy.
Methods:
A prospective study of patients with burn injury who presented to a regional urban burn center was conducted. Patient demographics and injury characteristics were collected and RapidTEG™ was performed on blood samples on admission and at regular time points over a 21-day period while hospitalized. Parameters analyzed were R (time to initial clot formation), α angle (rate of clot amplification), and MA (maximum clot strength). Coagulopathy was defined as either hypocoagulable or hypercoagulable with at least one parameter outside of the normal range.
Results:
The TEG profile of 88 burn patients with a mean age of 41.7 and a mean TBSA of injury of 22.2% were studied. Of these patients, 82% demonstrated abnormal metrics, with an observed trend from a normal or hypocoagulable state, to a more hypercoagulable state occurring between 48 and 72 hours. To further analyze this transition, patients without TEG analysis for three time points beyond 72 hours post-injury (due to death, discharge or decline to further participate) were excluded and the remaining subset of 33 patients were examined. This subset of patients had a mean age of 43.6 and a slightly higher mean TBSA of 33%. Of these patients, 15% (n=5) had R metrics within the hypocoagulable range on admission while no patients had hypercoagulable metrics. When comparing early time points versus late time points, greater than 72 hours, 79% had a statistically significant change (p<0.05) in parameters indicating a hypercoagulable state. This included all but two of the initially hypocoagulable subset of patients, one of which remained hypocoaguable throughout all time points. When stratified by injury severity 80% of the less than 10%TBSA (n=10), 86% of the 10-30%TBSA (n=14), 57% of the 31-50%TBSA (n=7), 100% of the 57-70%TBSA (n=1), and 100% of the greater than 70%TBSA (n=2) patients had significant changes in TEG parameters indicative of a hypercoagulable state. Initial fluid resuscitation and transfusions were explored for potential associations with the observed coagulopathy, but no significant correlations were identified.
Conclusions:
RapidTEG™ analysis demonstrates hypercoagulability in a time dependent fashion post burn injury. The clinical significance of this coagulopathy needs to be further explored and on going reseach efforts will be aimed at correlating these results with other functional and plasma assays to better understand coagulation after thermal injury.