Algorithm for activation of coagulation support treatment in multiple injured patients--cohort study

Early recognition and management of trauma related coagulopathy improves the outcome. Trauma facilities should implement an algorithm to identify the bleeding trauma patient with coagulopathy.

The scope of the paper is to identify the indicators of early coagulopathy and to optimize the indications for thromboelastometry and coagulation support.

Cohort study based on data from trauma registry.

Data of 493 major trauma patients treated in GH Celje from 2006 to 2014 were included into The TraumaRegister DGU^® (TR-DGU).

Patients were selected for inclusion into TR-DGU according to the following criteria: polytraumatized patients with Injury severity score (ISS) ≥ 18, patients with injuries to single region with AIS 5, patients with major injuries to a single region and abnormal vital signs. All patients that were dead on arrival to hospital, patients presented to hospital >24 h after the injury, and head injuries that occurred with a low energy mechanism in patients on anticoagulation drugs were excluded.

Two groups were formed (with or without coagulopathy). Mortality, morbidity, length of mechanical ventilation, ICU and hospital stay were used as outcome and compared between the groups. A coagulopathy prediction model (CPM) was developed to identify the patients who were at high risk of coagulopathy.

Coagulopathy was present in 51 % of patients. Severe injuries to the torso and limbs, infusion of >1000 ml of fluids in the prehospital settings, and hypotension were included into CPM. If all three criteria were present, the sensitivity of the model to predict coagulopathy was 93 %. By adding the blood gas analysis (BE ≤ -5), the specificity increased to 81.7 %.

Shortcomings of our analysis are mainly related to the quality of data in the registry that may not be comparable to a clinical trial where data are collected specifically to address a given issue.

The Criteria for activation of coagulation support treatment remain centre dependent. In our settings the CPM is the tool to select patients for ROTEM^® analysis. By adding data from blood gas analysis, treatment of coagulopathy is justifiable before complete test results are available.