The nature and timing of coagulation dysfunction in a cohort of trauma patients in the Australian pre-hospital setting

Daniel Bodnar; Emma Bosley; Steven Raven; Sue Williams; Glenn Ryan; Martin Wullschleger; Alfred K Lam

doi:10.1016/j.injury.2023.111124

The nature and timing of coagulation dysfunction in a cohort of trauma patients in the Australian pre-hospital setting

Injury. 2024 Jan;55(1):111124. doi: 10.1016/j.injury.2023.111124. Epub 2023 Oct 14.

Authors

Daniel Bodnar¹, Emma Bosley², Steven Raven³, Sue Williams⁴, Glenn Ryan⁵, Martin Wullschleger⁶, Alfred K Lam⁷

Affiliations

¹ Office of the Medical Director, Queensland Ambulance Service, Brisbane, Australia; School of Medicine and Dentistry, Griffith University, Gold Coast, Australia; Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Herston, Australia; Emergency Department, Queensland Children's Hospital, South Brisbane, Australia; School of Medicine, University of Queensland, Brisbane, Australia. Electronic address: daniel.bodnar@health.qld.gov.au.
² Office of the Medical Director, Queensland Ambulance Service, Brisbane, Australia; School of Clinical Sciences, Queensland University of Technology, Brisbane, Australia.
³ Office of the Medical Director, Queensland Ambulance Service, Brisbane, Australia.
⁴ Pathology Queensland Central Transfusion Laboratory, Royal Brisbane and Women's Hospital, Herston, Australia.
⁵ School of Medicine, University of Queensland, Brisbane, Australia; Emergency Department, The Princess Alexandra Hospital, Woolloongabba, Australia.
⁶ School of Medicine and Dentistry, Griffith University, Gold Coast, Australia; Trauma Service, Gold Coast University Hospital, Gold Coast, Australia.
⁷ School of Medicine and Dentistry, Griffith University, Gold Coast, Australia; School of Medicine, University of Queensland, Brisbane, Australia; Pathology Queensland, Gold Coast University Hospital, Gold Coast, Australia.

PMID: 37858445
DOI: 10.1016/j.injury.2023.111124

Abstract

Background: Acute Traumatic Coagulopathy (ATC) is a complex pathological process that is associated with patient mortality and increased blood transfusion requirements. It is evident on hospital arrival, but there is a paucity of information about the nature of ATC and the characteristics of patients that develop ATC in the pre-hospital setting. The objective of this study was to describe the nature and timing of coagulation dysfunction in a cohort of injured patients and to report on patient and pre-hospital factors associated with the development of ATC in the field.

Methods: This was a prospective observational study of a convenience sample of trauma patients. Patients had blood taken during the pre-hospital phase of care and evaluated for derangements in Conventional Coagulation Assays (CCA) and Rotational Thromboelastometry (ROTEM). Associations between coagulation derangement and pre-hospital factors and patient outcomes were evaluated.

Results: A total of 216 patients who had either a complete CCA or ROTEM were included in the analysis. One hundred and eighty (83 %) of patients were male, with a median injury severity score of 17 [interquartile range (IQR) 10-27] and median age of 34 years [IQR = 25.0-52.0]. Hypofibrinogenemia was the predominant abnormality seen, (CCA Hypofibrinogenemia: 51/193, 26 %; ROTEM hypofibrinogenemia: 65/204, 32 %). Increased CCA derangement, the presence of ROTEM coagulopathy, worsening INR, worsening FibTEM and decreasing fibrinogen concentration, were all associated with both mortality and early massive transfusion.

Conclusion: Clinically significant, multifaceted coagulopathy develops early in the clinical course, with hypofibrinogenemia being the predominant coagulopathy. In keeping with the ED literature, pre-hospital coagulation dysfunction was associated with mortality and early massive transfusion. Further work is required to identify strategies to identify and guide the pre-hospital management of the coagulation dysfunction seen in trauma.

Keywords: Coagulopathy; Emergency medical system; Hypofibrinogenaemia; Pre-hospital; Trauma.

Publication types

Observational Study

MeSH terms

Adult
Afibrinogenemia*
Australia / epidemiology
Blood Coagulation
Blood Coagulation Disorders* / etiology
Female
Hospitals
Humans
Male
Middle Aged
Thrombelastography
Wounds and Injuries* / complications
Wounds and Injuries* / therapy