R. Chang1, E. Fox1, T. Greene1, M. Swartz1, S. DeSantis1, D. Stein6, E. Bulger4, S. Melton8, M. Goodman2, M. Schreiber5, M. Zielinski3, T. O’Keeffe9, K. Inaba7, J. Tomasek1, J. Podbielski1, C. Wade1, J. Holcomb1 1University Of Texas Health Science Center At Houston,Houston, TX, USA 2University Of Cincinnati,Cincinnati, OH, USA 3Mayo Clinic,Rochester, MN, USA 4University Of Washington,Seattle, WA, USA 5Oregon Health And Science University,Portland, OR, USA 6University Of Maryland,Baltimore, MD, USA 7University Of Southern California,Los Angeles, CA, USA 8University Of Alabama At Birmingham,Birmingham, AL, USA 9University Of Arizona Medical Center,Tuscon, AZ, USA
Introduction: Laboratory evidence of coagulopathy is observed in 25% of severely injured trauma patients, but clinically-evident coagulopathy (CC) is not well-described. This study investigates the characteristics of CC and seeks to identify any potentially modifiable prehospital risk factors of CC.
Methods: The Prehospital Resuscitation on Helicopters Study (PROHS) was a prospective observational study of adult trauma patients transported by helicopter from the scene to one of nine Level 1 trauma centers in 2015. Predefined highest-risk criteria were any of the following during helicopter transport: heart rate >120 bpm, SBP ≤90 mmHg, penetrating truncal injury, tourniquet application, pelvic binder application, or intubation. Patients meeting any highest-risk criteria were divided into 2 groups based on presence of CC, defined as surgeon-confirmed bleeding from uninjured sites or injured sites not controllable by normal means (e.g. sutures). Purposeful multiple logistic regression was performed to identify potentially modifiable prehospital risk factors of CC.
Results: Of the 2341 patients enrolled, 1058 (45%) met highest risk criteria and were divided into CC (n=43, 4%) and not CC (n=1015, 96%) groups. CC patients were older (median age 50 vs 38), more severely injured (median ISS 30 vs 17), and were more likely to have had penetrating trauma (33% vs 19%), prehospital RBCs and/or plasma (56% vs 12%), and laboratory evidence of coagulopathy on admission (86% vs 46%) (all p<0.05). Prehospital crystalloid volumes were similar (median 200 vs 250ml), and transfusion ratios were balanced. CC patients had increased mortality at 30 days (60% vs 15%, p<0.01); although the leading cause of death was TBI in both groups (54% vs 66%), exsanguination was increased in CC patients (38% vs 18%, p<0.01). Transport time, prehospital RBC or plasma units, and crystalloid volume were not significant predictors of CC on multiple logistic regression after controlling for age, ISS, mechanism, admission GCS, and availability of prehospital blood products.
Conclusion:
Despite the relatively common finding of laboratory evidence of coagulopathy, CC was rare (4%) but associated with substantial mortality. No obvious modifiable prehospital risk factors of CC were identified.