Citation

Coleman JR, Moore EE, Samuels JM, Cohen MJ, Silliman CC, Ghasabyan A, Chandler J, Butenas S. J. Am. Coll. Surg. 2021; ePub(ePub): ePub.

Copyright

(Copyright © 2021, American College of Surgeons, Publisher Elsevier Publishing)

DOI

10.1016/j.jamcollsurg.2020.12.058

PMID

unavailable

Abstract

BACKGROUND: Despite the prevalence of hypocoagulability after injury, the majority of trauma patients paradoxically present with elevated thrombin generation (TG). While several studies have examined plasma TG post-injury, this has not been assessed in whole blood. We hypothesize that whole blood TG is lower in hypocoagulopathy, and TG effectively predicts massive transfusion. STUDY DESIGN: Blood was collected from trauma activation patients at an urban Level-1 trauma center. Whole blood TG was performed with a prototype point-of-care device. Whole blood TG values in healthy volunteers were compared to trauma patients, and TG values were examined in trauma patients with shock and massive transfusion requirement (MT).

RESULTS: Overall, 118 patients were included (Table 1). Compared to healthy volunteers, trauma patients overall presented with more robust TG; however, those arriving in shock (n=23) had a depressed TG, with significantly lower peak thrombin (88.3 versus 133.0 nM, p=0.01) and slower maximum rate of thrombin generation (27.4 versus 48.3 nM/min, p=0.04). Patients who required massive transfusion (n=26) had significantly decreased TG, with a longer lag time (median 4.8 min versus 3.9 min, p=0.04), decreased peak thrombin (median 71.4 nM versus 124.2 nM, p=0.0003), and lower maximum rate of TG (median 15.8 nM/min versus 39.4 nM/min, p=0.01). AUROC analysis revealed lag time (AUROC 0.6), peak thrombin (AUROC 0.7), and maximum rate of TG (AUROC 0.7) predict early MT.

CONCLUSION: These data challenge the prevailing bias that all trauma patients present with elevated TG and highlight that deficient thrombin contributes to the hypocoagulopathic phenotype of trauma-induced coagulopathy. Further, whole blood TG predicts massive transfusion, suggesting point of care whole blood TG may be a useful tool for diagnostic and therapeutic strategies in trauma.

Language: en

Keywords

hemostasis; massive transfusion; thrombelastography; Thrombin generation; trauma-induced coagulopathy