C. R. Reed3, T. Fitzgerald2, H. Leraas3, R. Kamyszek5, C. Vatsaas1, C. Ray4, J. Otto2, E. Tracy2, S. K. Agarwal1 1Duke University Medical Center,Trauma And Critical Care,Durham, NC, USA 2Duke University Medical Center,Pediatric General Surgery,Durham, NC, USA 3Duke University Medical Center,General Surgery Residency,Durham, NC, USA 4Duke University Medical Center,Pediatric Critical Care,Durham, NC, USA 5Duke University Medical Center,School Of Medicine,Durham, NC, USA
Introduction
Trauma-induced coagulopathy (TIC) is associated with worse outcomes. The coagulation system normally undergoes development throughout life. TIC has been described in adults and sparsely for children, but no studies have directly compared incidence and outcomes of TIC among infants, children, adults, and older adults.
Methods:
A single-institution retrospective review of all level 1 and 2 trauma activations from 2013-2017 at a Level 1 trauma center was performed. Inclusion criteria were complete records and an injury severity score (ISS) >= 9. Data were collected and analyzed for patient age, ISS, mechanism, mortality, prothrombin time or international normalized ratio (PT or INR), partial thromboplastin time (PTT), and fibrinogen. The patient cohort was divided into age groups reflecting normal development to evaluate both patient factors and lab values in infants (=< 2 years), children (3-13 years), adults (14-64 years), and older adults (>= 65 years). Using bivariate statistics, we compared the adult control group to the other age groups. Coagulopathy was defined as abnormal PTT (>= 38s) or INR (>= 1.3). Normal fibrinogen was defined as plasma levels 150-400 mg/dL. Statistical significance was declared if p < 0.05.
Results:
During the study period, 1,983 patients met the inclusion criteria and were analyzed. Overall mortality in all groups was 12% and rates of coagulopathy by abnormal PTT and INR were 7% and 10% respectively. Adults had a slightly higher median ISS compared to the other age groups. Despite their lower ISS, infants and children were more likely to have coagulopathy on arrival using both PTT and INR definitions, and older adults were more likely to be coagulopathic via INR (p < 0.05). Nearly 20% of patients =< 2 years presented with abnormal coagulation studies and 32% of these infants were also hypofibrinogenemic on arrival compared to 9% of adults (p = 0.0019). Median fibrinogen on arrival did increase with each age group, and older adults were more likely to be hyperfibrinogenemic compared to adults (19% vs. 5%, p < 0.0001). Both coagulopathy and hypofibrinogenemia were associated with mortality in subgroup analyses of all age groups with the notable exception of older adults, where abnormal PTT and INR were not associated with mortality.
Conclusion:
The incidence of TIC differs by age group and may suggest differences in hematologic development of the coagulation system that should be considered when caring for these patients, especially when evaluating patients for transfusions and hemostatic adjuncts. Further study should focus on outcomes of resuscitation, correction of coagulopathy, thrombosis, and other outcomes at the extremes of age.
