12 Maegele
World J Emerg Med, Vol 1, No 1, 2010
Original Article
Acute traumatic coagulopathy: Incidence, risk stratification and therapeutic options Marc Maegele Department of Trauma and Orthopedic Surgery and Institute for Research in Operative Medicine (IFOM), University of Witten/Herdecke, Cologne-Merheim Medical Center (CMMC), Ostmerheimerstr. 200, D-51109 Cologne, Germany Corresponding Author: Marc Maegele, Email: [email protected]
BACKGROUND: Uncontrolled hemorrhage is responsible for over 50% of all trauma-related deaths within the first 48 hours after admission. Clinical observations together with recent research resulted in an appreciation of the central role of coagulopathy in acute trauma care. A synopsis is presented of different retrospective analyses based upon datasets from severe multiply injured patients derived from the TR-DGU database (Trauma Registry of the Deutsche Gesellschaft für Unfallchirurgie (DGU)/ German Society of Trauma Surgery) with respect to frequency, risk stratification and therapeutic options of acute traumatic coagulopathy (ATC). METHODS: The synopsis of different analyses based upon the datasets from severe multiply injured patients derived from the TR-DGU database and development/validation of a scoring system (TASH-score = Trauma Associated Severe Hemorrhage) that allows an early and reliable estimation for the probability of massive transfusion as a surrogate for life-threatening hemorrhage after severe multiple injuries. RESULTS: The high frequency of ATC upon emergency room admission is associated with significant morbidity and mortality in multiply injured patients. The TASH-score is recognized as an easy-to-calculate and valid scoring system to predict the individual´s probability for massive transfusion and thus ongoing life-threatening hemorrhage at a very early stage after severe multiple injuries. CONCLUSION: An early aggressive management of ATC including a more balanced administration of blood products to improve outcome is advocated. KEY WORDS: Coagulopathy; Epidemiology; Management; Risk stratification;Trauma World J Emerg Med 2010;1(1):12-21
INTRODUCTION Trauma is the leading cause of death in persons aged 5 to 44 years[1] and accounts for approximately 10% of all deaths in general.[2] Despite substantial improvement in acute trauma care, uncontrolled haemorrhage is responsible for over 50% of all trauma-related deaths within the first 48 hours after admission.[3] These clinical observations together with recent research resulted in a new appreciation of the central role of coagulopathy in acute trauma care. Current literature suggests that acute traumatic coagulopathy (ATC) is multifactorial with certain mechanisms being predominant whereas others manifest www.wjem.org © 2010 World Journal of Emergency Medicine
only in specific clinical states[4] (Figure 1). To date, six key initiators of coagulopathy in trauma have been described as tissue trauma, shock, hemodilution, hypothermia, acidemia, and inflammation.[4] Most recently, Brohi et al[5] emphasized the role of hypoperfusion for the initiation of ATC. As each abnormality itself may substantially exacerbate the other, a downward spiral is initiated rapidly and accelerates to death.[6] However, the adverse outcomes from uncontrolled non-surgical hemorrhage and disturbed hemostasis are not restricted to mortality only but also include organ dysfunction and loss due to prolonged hemorrhagic shock as well as the early termination of
World J Emerg Med, Vol 1, No 1, 2010
13
Hemorrhage
Trauma Predisposition
Cocommitant disease, Medication, Genetics)
Shock Rescusitation Hypoperfusion /Hypoxia
Tissue damage
Dilution
Acidemia Consumption
Inflammation
Hypothermia Hyperfibrinolysis
ATC Figure 1. Potential mechanisms underlying ATC. Besides dilutional coagulopathy, hemorrhage may also induce shock followed by acidemia and hypothermia, further triggering coagulopathy to form the so-called "lethal triad". Trauma with shock, hypoperfusion and hypoxia can also cause ATC associated with further consumption and hyperfibrinolysis. The clinical importance of inflammation for the development of ATC has not yet been fully understood.[4]
surgical procedures in order to save life.[6] Thus, early recognition accompanied by adequate and aggressive management of ATC would substantially reduce mortality and improve outcomes in severely injured patients.[7] A comprehensive review of the mechanisms underlying ATC has been published.[4] The present study has three purposes. First, the clinical impact of the problem is emphasized by providing actual frequency rates of ATC upon emergency room (ER) admission. Second, as early identification of patients at risk for severe bleeding requiring massive transfusion (MT) is rather difficult in the acute clinical setting but may substantially influence therapeutic strategies towards a more aggressive stabilization of the disturbed hemostatic system, a simple scoring system allowing an early and reliable estimation for the probability of MT as a surrogate for life-threatening hemorrhage after severe multiple injuries are presented. Third, key issues are considered during acute care of the bleeding trauma patient including novel approaches towards a more balanced transfusion therapy.
Scoring of the DGU [8] which was founded in 1993 i run by a small steering group from different trauma centers in Germany (Working Group on Polytrauma AG Polytrauma). It is a prospective, multicenter standardized and anonymous documentation of multiply injured trauma patients at four consecutive post trauma stages from injury to hospital discharge: pre hospital phase; emergency room and initial surgery (unti admission to the intensive care unit (ICU)); ICU; and outcome status at discharge and description of injuries and procedures. The registry contains detailed information on demographics, injury pattern, co-morbidities, pre- and in hospital management, time course, relevant laboratory findings including data on transfusion, and outcome of each individual. Through the 2006 data from a tota of 29 353 trauma victims have been input the registry approximately 3000 new cases are added each year. Since the introduction of the on-line version of the registry in 2002, the use of fresh frozen plasma (FFP) units i routinely documented. Between 2002 and 2006, 17 935 patients have been input the registry. Currently, there are 140 hospitals affiliated with the registry, mostly from Germany (n=90), of which 100 are actually contributing data into the database. Contributing hospitals are mostly level I trauma centers. The data are not dominated by single trauma centers but this does not exclude potentia center effects due to different levels and strategies o care. The TR-DGU is not an obligatory registry. The participation is free of charge and data are contributed on a voluntary basis. It is estimated that from the tota number of severe trauma cases in Germany, approximately 30% are covered by the registry. The trauma registry is approved by the review board of the DGU and is in compliance with the institutional requirements.
RESULTS METHODS The data were collected from different analyses of datasets from severe multiple injured patients derived from the Trauma Registry of the Deutsche Gesellschaft für Unfallchirurgie (TR-DGU) database/ Arbeitsgemeinschaft Scoring of the German Society of Trauma Surgery(DGU).[8]
TR-DGU The TR-DGU database/ Arbeitsgemeinschaft
Frequency of ATC in multiple injuries upon ER admission A retrospective analysis using the TR-DGU database was conducted to determine to what extent clinically relevant coagulopathy has already been established upon ER admission, and whether its presence was associated with the amount of intravenous fluids administered intravenously during the pre-hospital phase of care, with the severity of injury, and with impaired outcome and mortality.[9] Altogether 8 724 patients with complete data sets were screened. Coagulopathy was defined by the presence of abnormal coagulation parameters upon ER www.wjem.org arrival of the patient, i.e. prothrombin time test (Quick'
14 Maegele
www.wjem.org
Patients with coagulopathy (%)
100 90 80 70 60 50 40 30 20 10 0
ISS 1-15 ISS 16-24 ISS 25-49 ISS 50-75
World J Emerg Med, Vol 1, No 1, 2010
Original Article
Acute traumatic coagulopathy: Incidence, risk stratification and therapeutic options Marc Maegele Department of Trauma and Orthopedic Surgery and Institute for Research in Operative Medicine (IFOM), University of Witten/Herdecke, Cologne-Merheim Medical Center (CMMC), Ostmerheimerstr. 200, D-51109 Cologne, Germany Corresponding Author: Marc Maegele, Email: [email protected]
BACKGROUND: Uncontrolled hemorrhage is responsible for over 50% of all trauma-related deaths within the first 48 hours after admission. Clinical observations together with recent research resulted in an appreciation of the central role of coagulopathy in acute trauma care. A synopsis is presented of different retrospective analyses based upon datasets from severe multiply injured patients derived from the TR-DGU database (Trauma Registry of the Deutsche Gesellschaft für Unfallchirurgie (DGU)/ German Society of Trauma Surgery) with respect to frequency, risk stratification and therapeutic options of acute traumatic coagulopathy (ATC). METHODS: The synopsis of different analyses based upon the datasets from severe multiply injured patients derived from the TR-DGU database and development/validation of a scoring system (TASH-score = Trauma Associated Severe Hemorrhage) that allows an early and reliable estimation for the probability of massive transfusion as a surrogate for life-threatening hemorrhage after severe multiple injuries. RESULTS: The high frequency of ATC upon emergency room admission is associated with significant morbidity and mortality in multiply injured patients. The TASH-score is recognized as an easy-to-calculate and valid scoring system to predict the individual´s probability for massive transfusion and thus ongoing life-threatening hemorrhage at a very early stage after severe multiple injuries. CONCLUSION: An early aggressive management of ATC including a more balanced administration of blood products to improve outcome is advocated. KEY WORDS: Coagulopathy; Epidemiology; Management; Risk stratification;Trauma World J Emerg Med 2010;1(1):12-21
INTRODUCTION Trauma is the leading cause of death in persons aged 5 to 44 years[1] and accounts for approximately 10% of all deaths in general.[2] Despite substantial improvement in acute trauma care, uncontrolled haemorrhage is responsible for over 50% of all trauma-related deaths within the first 48 hours after admission.[3] These clinical observations together with recent research resulted in a new appreciation of the central role of coagulopathy in acute trauma care. Current literature suggests that acute traumatic coagulopathy (ATC) is multifactorial with certain mechanisms being predominant whereas others manifest www.wjem.org © 2010 World Journal of Emergency Medicine
only in specific clinical states[4] (Figure 1). To date, six key initiators of coagulopathy in trauma have been described as tissue trauma, shock, hemodilution, hypothermia, acidemia, and inflammation.[4] Most recently, Brohi et al[5] emphasized the role of hypoperfusion for the initiation of ATC. As each abnormality itself may substantially exacerbate the other, a downward spiral is initiated rapidly and accelerates to death.[6] However, the adverse outcomes from uncontrolled non-surgical hemorrhage and disturbed hemostasis are not restricted to mortality only but also include organ dysfunction and loss due to prolonged hemorrhagic shock as well as the early termination of
World J Emerg Med, Vol 1, No 1, 2010
13
Hemorrhage
Trauma Predisposition
Cocommitant disease, Medication, Genetics)
Shock Rescusitation Hypoperfusion /Hypoxia
Tissue damage
Dilution
Acidemia Consumption
Inflammation
Hypothermia Hyperfibrinolysis
ATC Figure 1. Potential mechanisms underlying ATC. Besides dilutional coagulopathy, hemorrhage may also induce shock followed by acidemia and hypothermia, further triggering coagulopathy to form the so-called "lethal triad". Trauma with shock, hypoperfusion and hypoxia can also cause ATC associated with further consumption and hyperfibrinolysis. The clinical importance of inflammation for the development of ATC has not yet been fully understood.[4]
surgical procedures in order to save life.[6] Thus, early recognition accompanied by adequate and aggressive management of ATC would substantially reduce mortality and improve outcomes in severely injured patients.[7] A comprehensive review of the mechanisms underlying ATC has been published.[4] The present study has three purposes. First, the clinical impact of the problem is emphasized by providing actual frequency rates of ATC upon emergency room (ER) admission. Second, as early identification of patients at risk for severe bleeding requiring massive transfusion (MT) is rather difficult in the acute clinical setting but may substantially influence therapeutic strategies towards a more aggressive stabilization of the disturbed hemostatic system, a simple scoring system allowing an early and reliable estimation for the probability of MT as a surrogate for life-threatening hemorrhage after severe multiple injuries are presented. Third, key issues are considered during acute care of the bleeding trauma patient including novel approaches towards a more balanced transfusion therapy.
Scoring of the DGU [8] which was founded in 1993 i run by a small steering group from different trauma centers in Germany (Working Group on Polytrauma AG Polytrauma). It is a prospective, multicenter standardized and anonymous documentation of multiply injured trauma patients at four consecutive post trauma stages from injury to hospital discharge: pre hospital phase; emergency room and initial surgery (unti admission to the intensive care unit (ICU)); ICU; and outcome status at discharge and description of injuries and procedures. The registry contains detailed information on demographics, injury pattern, co-morbidities, pre- and in hospital management, time course, relevant laboratory findings including data on transfusion, and outcome of each individual. Through the 2006 data from a tota of 29 353 trauma victims have been input the registry approximately 3000 new cases are added each year. Since the introduction of the on-line version of the registry in 2002, the use of fresh frozen plasma (FFP) units i routinely documented. Between 2002 and 2006, 17 935 patients have been input the registry. Currently, there are 140 hospitals affiliated with the registry, mostly from Germany (n=90), of which 100 are actually contributing data into the database. Contributing hospitals are mostly level I trauma centers. The data are not dominated by single trauma centers but this does not exclude potentia center effects due to different levels and strategies o care. The TR-DGU is not an obligatory registry. The participation is free of charge and data are contributed on a voluntary basis. It is estimated that from the tota number of severe trauma cases in Germany, approximately 30% are covered by the registry. The trauma registry is approved by the review board of the DGU and is in compliance with the institutional requirements.
RESULTS METHODS The data were collected from different analyses of datasets from severe multiple injured patients derived from the Trauma Registry of the Deutsche Gesellschaft für Unfallchirurgie (TR-DGU) database/ Arbeitsgemeinschaft Scoring of the German Society of Trauma Surgery(DGU).[8]
TR-DGU The TR-DGU database/ Arbeitsgemeinschaft
Frequency of ATC in multiple injuries upon ER admission A retrospective analysis using the TR-DGU database was conducted to determine to what extent clinically relevant coagulopathy has already been established upon ER admission, and whether its presence was associated with the amount of intravenous fluids administered intravenously during the pre-hospital phase of care, with the severity of injury, and with impaired outcome and mortality.[9] Altogether 8 724 patients with complete data sets were screened. Coagulopathy was defined by the presence of abnormal coagulation parameters upon ER www.wjem.org arrival of the patient, i.e. prothrombin time test (Quick'
14 Maegele
www.wjem.org
Patients with coagulopathy (%)
100 90 80 70 60 50 40 30 20 10 0
ISS 1-15 ISS 16-24 ISS 25-49 ISS 50-75
