Targeting resuscitation to normalization of coagulating status: Hyper and hypocoagulability after severe injury are both associated with increased mortality

Abstract

Introduction: The prevalence and impact of hypercoagulability (hypo) in severely injured patients early after injury remains unclear. We hypothesize that the predominant phenotype of postinjury coagulopathy is hypercoagulability (hyper) and it is associated with increased mortality.

Material and methods: Blood samples from 141 healthy volunteers assayed with thrombelastography (TEG) were used to identify thresholds of hypo and hypercoagulability (above 95th/below the 5^thpercentile) in four TEG indices. These cutoffs were subsequently evaluated in severely injured trauma patients (ISS>15) from two level 1 trauma centers.

Results: 2540 patients with a median ISS of 25 were analyzed. Normal TEG was present in 36% of patients. Hyper was found in 38% of patients, with mixed (11%) and hypo (15%) being less common. Compared to normal coagulation patients and after controlling for age, sex, blood pressure, and injury hyper (0.013), mixed (p < 0.001) and hypo (p < 0.001) were all independent predictors of mortality.

Conclusion: These data support the ongoing need for goal directed resuscitation in trauma patients, it appears the optimal resuscitation strategy should be targeted towards normalization of coagulation status as both early hyper and hypocoagulability are associated with increased mortality.

Keywords: Fibrinolysis; Hypercoagulability; Massive transfusion; Trauma; Trauma induced coagulopathy.