Abnormalities of laboratory coagulation tests versus clinically evident coagulopathic bleeding: results from the prehospital resuscitation on helicopters study (PROHS)

PROHS Study Group

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5 Citations (Scopus)

Abstract

Background: Laboratory-based evidence of coagulopathy (LC) is observed in 25-35% of trauma patients, but clinically-evident coagulopathy (CC) is not well described. Methods: Prospective observational study of adult trauma patients transported by helicopter from the scene to nine Level 1 trauma centers in 2015. Patients meeting predefined highest-risk criteria were divided into CC+ (predefined as surgeon-confirmed bleeding from uninjured sites or injured sites not controllable by sutures) or CC-. We used a mixed-effects, Poisson regression with robust error variance to test the hypothesis that abnormalities on rapid thrombelastography (r-TEG) and international normalized ratio (INR) were independently associated with CC+. Results: Of 1,019 highest-risk patients, CC+ (n=41, 4%) were more severely injured (median ISS 32 vs 17), had evidence of LC on r-TEG and INR, received more transfused blood products at 4 hours (37 vs 0 units), and had greater 30-day mortality (59% vs 12%) than CC- (n=978, 96%). The overall incidence of LC was 39%. 30-day mortality was 22% vs 9% in those with and without LC. In two separate models, r-TEG K-time >2.5 min (RR 1.3, 95% CI 1.1-1.7), r-TEG mA <55 mm (RR 2.5, 95% CI 2.0-3.2), platelet count <150 x 109/L (RR 1.2, 95% CI 1.1-1.3), and INR >1.5 (RR 5.4, 95% CI 1.8-16.3) were independently associated with CC+. A combined regression model was not generated because too few patients underwent both r-TEG and INR. Conclusion: CC was rare compared to LC. CC was associated with poor outcomes and impairment of both clotting factor and platelet-mediated coagulation components.

Original languageEnglish (US)
Pages (from-to)819-826
Number of pages8
JournalSurgery (United States)
Volume163
Issue number4
DOIs
StatePublished - Apr 2018

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Thrombelastography
Aircraft
Resuscitation
International Normalized Ratio
Hemorrhage
Blood Coagulation Factors
Mortality
Trauma Centers
Wounds and Injuries
Sutures
Observational Studies
Blood Platelets
Prospective Studies
Incidence

ASJC Scopus subject areas

  • Surgery

Cite this

@article{ad8417fbda7941a2af31665061e915a3,
title = "Abnormalities of laboratory coagulation tests versus clinically evident coagulopathic bleeding: results from the prehospital resuscitation on helicopters study (PROHS)",
abstract = "Background: Laboratory-based evidence of coagulopathy (LC) is observed in 25-35{\%} of trauma patients, but clinically-evident coagulopathy (CC) is not well described. Methods: Prospective observational study of adult trauma patients transported by helicopter from the scene to nine Level 1 trauma centers in 2015. Patients meeting predefined highest-risk criteria were divided into CC+ (predefined as surgeon-confirmed bleeding from uninjured sites or injured sites not controllable by sutures) or CC-. We used a mixed-effects, Poisson regression with robust error variance to test the hypothesis that abnormalities on rapid thrombelastography (r-TEG) and international normalized ratio (INR) were independently associated with CC+. Results: Of 1,019 highest-risk patients, CC+ (n=41, 4{\%}) were more severely injured (median ISS 32 vs 17), had evidence of LC on r-TEG and INR, received more transfused blood products at 4 hours (37 vs 0 units), and had greater 30-day mortality (59{\%} vs 12{\%}) than CC- (n=978, 96{\%}). The overall incidence of LC was 39{\%}. 30-day mortality was 22{\%} vs 9{\%} in those with and without LC. In two separate models, r-TEG K-time >2.5 min (RR 1.3, 95{\%} CI 1.1-1.7), r-TEG mA <55 mm (RR 2.5, 95{\%} CI 2.0-3.2), platelet count <150 x 109/L (RR 1.2, 95{\%} CI 1.1-1.3), and INR >1.5 (RR 5.4, 95{\%} CI 1.8-16.3) were independently associated with CC+. A combined regression model was not generated because too few patients underwent both r-TEG and INR. Conclusion: CC was rare compared to LC. CC was associated with poor outcomes and impairment of both clotting factor and platelet-mediated coagulation components.",
author = "{PROHS Study Group} and Ronald Chang and Fox, {Erin E.} and Greene, {Thomas J.} and Swartz, {Michael D.} and DeSantis, {Stacia M.} and Stein, {Deborah M.} and Bulger, {Eileen M.} and Melton, {Sherry M.} and Goodman, {Michael D.} and Schreiber, {Martin A.} and Zielinski, {Martin D.} and Terence O'Keeffe and Terence OKeeffe and Tomasek, {Jeffrey S.} and Podbielski, {Jeanette M.} and Savitri Appana and Misung Yi and Johansson, {P{\"a}r I.} and Henriksen, {Hanne H.} and Jakob Stensballe and Jacob Steinmetz and Wade, {Charles E.} and Holcomb, {John B.} and Holcomb, {John B.} and Wade, {Charles E.} and Fox, {Erin E.} and Ronald Chang and Podbielski, {Jeanette M.} and Tomasek, {Jeffrey S.} and {del Junco}, {Deborah J.} and Swartz, {Michael D.} and DeSantis, {Stacia M.} and Appana, {Savitri N.} and Greene, {Thomas J.} and Misung Yi and Gonzalez, {Michael O.} and Sarah Baraniuk and {van Belle}, Gerald and Leroux, {Brian G.} and Howard, {Carrie L.} and Amanda Haymaker and Stein, {Deborah M.} and Scalea, {Thomas M.} and Benjamin Ayd and Pratik Das and Herrera, {Anthony V.} and Bulger, {Eileen M.} and Robinson, {Bryce R.H.} and Patricia Klotz and Aniqa Minhas",
year = "2018",
month = "4",
doi = "10.1016/j.surg.2017.10.050",
language = "English (US)",
volume = "163",
pages = "819--826",
journal = "Surgery (United States)",
issn = "0039-6060",
publisher = "Mosby Inc.",
number = "4",

}

TY - JOUR

T1 - Abnormalities of laboratory coagulation tests versus clinically evident coagulopathic bleeding

T2 - results from the prehospital resuscitation on helicopters study (PROHS)

AU - PROHS Study Group

AU - Chang, Ronald

AU - Fox, Erin E.

AU - Greene, Thomas J.

AU - Swartz, Michael D.

AU - DeSantis, Stacia M.

AU - Stein, Deborah M.

AU - Bulger, Eileen M.

AU - Melton, Sherry M.

AU - Goodman, Michael D.

AU - Schreiber, Martin A.

AU - Zielinski, Martin D.

AU - O'Keeffe, Terence

AU - OKeeffe, Terence

AU - Tomasek, Jeffrey S.

AU - Podbielski, Jeanette M.

AU - Appana, Savitri

AU - Yi, Misung

AU - Johansson, Pär I.

AU - Henriksen, Hanne H.

AU - Stensballe, Jakob

AU - Steinmetz, Jacob

AU - Wade, Charles E.

AU - Holcomb, John B.

AU - Holcomb, John B.

AU - Wade, Charles E.

AU - Fox, Erin E.

AU - Chang, Ronald

AU - Podbielski, Jeanette M.

AU - Tomasek, Jeffrey S.

AU - del Junco, Deborah J.

AU - Swartz, Michael D.

AU - DeSantis, Stacia M.

AU - Appana, Savitri N.

AU - Greene, Thomas J.

AU - Yi, Misung

AU - Gonzalez, Michael O.

AU - Baraniuk, Sarah

AU - van Belle, Gerald

AU - Leroux, Brian G.

AU - Howard, Carrie L.

AU - Haymaker, Amanda

AU - Stein, Deborah M.

AU - Scalea, Thomas M.

AU - Ayd, Benjamin

AU - Das, Pratik

AU - Herrera, Anthony V.

AU - Bulger, Eileen M.

AU - Robinson, Bryce R.H.

AU - Klotz, Patricia

AU - Minhas, Aniqa

PY - 2018/4

Y1 - 2018/4

N2 - Background: Laboratory-based evidence of coagulopathy (LC) is observed in 25-35% of trauma patients, but clinically-evident coagulopathy (CC) is not well described. Methods: Prospective observational study of adult trauma patients transported by helicopter from the scene to nine Level 1 trauma centers in 2015. Patients meeting predefined highest-risk criteria were divided into CC+ (predefined as surgeon-confirmed bleeding from uninjured sites or injured sites not controllable by sutures) or CC-. We used a mixed-effects, Poisson regression with robust error variance to test the hypothesis that abnormalities on rapid thrombelastography (r-TEG) and international normalized ratio (INR) were independently associated with CC+. Results: Of 1,019 highest-risk patients, CC+ (n=41, 4%) were more severely injured (median ISS 32 vs 17), had evidence of LC on r-TEG and INR, received more transfused blood products at 4 hours (37 vs 0 units), and had greater 30-day mortality (59% vs 12%) than CC- (n=978, 96%). The overall incidence of LC was 39%. 30-day mortality was 22% vs 9% in those with and without LC. In two separate models, r-TEG K-time >2.5 min (RR 1.3, 95% CI 1.1-1.7), r-TEG mA <55 mm (RR 2.5, 95% CI 2.0-3.2), platelet count <150 x 109/L (RR 1.2, 95% CI 1.1-1.3), and INR >1.5 (RR 5.4, 95% CI 1.8-16.3) were independently associated with CC+. A combined regression model was not generated because too few patients underwent both r-TEG and INR. Conclusion: CC was rare compared to LC. CC was associated with poor outcomes and impairment of both clotting factor and platelet-mediated coagulation components.

AB - Background: Laboratory-based evidence of coagulopathy (LC) is observed in 25-35% of trauma patients, but clinically-evident coagulopathy (CC) is not well described. Methods: Prospective observational study of adult trauma patients transported by helicopter from the scene to nine Level 1 trauma centers in 2015. Patients meeting predefined highest-risk criteria were divided into CC+ (predefined as surgeon-confirmed bleeding from uninjured sites or injured sites not controllable by sutures) or CC-. We used a mixed-effects, Poisson regression with robust error variance to test the hypothesis that abnormalities on rapid thrombelastography (r-TEG) and international normalized ratio (INR) were independently associated with CC+. Results: Of 1,019 highest-risk patients, CC+ (n=41, 4%) were more severely injured (median ISS 32 vs 17), had evidence of LC on r-TEG and INR, received more transfused blood products at 4 hours (37 vs 0 units), and had greater 30-day mortality (59% vs 12%) than CC- (n=978, 96%). The overall incidence of LC was 39%. 30-day mortality was 22% vs 9% in those with and without LC. In two separate models, r-TEG K-time >2.5 min (RR 1.3, 95% CI 1.1-1.7), r-TEG mA <55 mm (RR 2.5, 95% CI 2.0-3.2), platelet count <150 x 109/L (RR 1.2, 95% CI 1.1-1.3), and INR >1.5 (RR 5.4, 95% CI 1.8-16.3) were independently associated with CC+. A combined regression model was not generated because too few patients underwent both r-TEG and INR. Conclusion: CC was rare compared to LC. CC was associated with poor outcomes and impairment of both clotting factor and platelet-mediated coagulation components.

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U2 - 10.1016/j.surg.2017.10.050

DO - 10.1016/j.surg.2017.10.050

M3 - Article

C2 - 29289392

AN - SCOPUS:85039165623

VL - 163

SP - 819

EP - 826

JO - Surgery (United States)

JF - Surgery (United States)

SN - 0039-6060

IS - 4

ER -