Skip to main content
Key Specialties
Cardiology Diabetology Endocrinology Gastroenterology Geriatrics and Gerontology Gynecology and Obstetrics Hematology Infectious Disease Internal Medicine Nephrology Neurology Oncology Pediatrics Respiratory Medicine Rheumatology Surgery
Congress Coverage
2024 ACC Congress 2023 ESMO Congress 2023 EASD Congress 2023 ERS Congress 2023 ESC Congress
Clinical Collections
Advances in Alzheimer’s

At a glance: The STEP trials

A round-up of the STEP phase 3 clinical trials evaluating semaglutide for weight loss in people with overweight or obesity.
ADVANCED SEARCH
Log in
Top
Critical Care
Published in: Critical Care 6/2011

Open Access 01-12-2011 | Research

Disseminated intravascular coagulation or acute coagulopathy of trauma shock early after trauma? An observational study

Authors: Pär I Johansson, Anne Marie Sørensen, Anders Perner, Karen Lise Welling, Michael Wanscher, Claus F Larsen, Sisse R Ostrowski

Published in: Critical Care | Issue 6/2011

Login to get access

Abstract

Introduction

It is debated whether early trauma-induced coagulopathy (TIC) in severely injured patients reflects disseminated intravascular coagulation (DIC) with a fibrinolytic phenotype, acute coagulopathy of trauma shock (ACoTS) or yet other entities. This study investigated the prevalence of overt DIC and ACoTS in trauma patients and characterized these conditions based on their biomarker profiles.

Methods

An observational study was carried out at a single Level I Trauma Center. Eighty adult trauma patients (≥18 years) who met criteria for full trauma team activation and had an arterial cannula inserted were included. Blood was sampled a median of 68 minutes (IQR 48 to 88) post-injury. Data on demography, biochemistry, injury severity score (ISS) and mortality were recorded. Plasma/serum was analyzed for biomarkers reflecting tissue/endothelial cell/glycocalyx damage (histone-complexed DNA fragments, Annexin V, thrombomodulin, syndecan-1), coagulation activation/inhibition (prothrombinfragment 1+2, thrombin/antithrombin-complexes, antithrombin, protein C, activated protein C, endothelial protein C receptor, protein S, tissue factor pathway inhibitor, vWF), factor consumption (fibrinogen, FXIII), fibrinolysis (D-dimer, tissue-type plasminogen activator, plasminogen activator inhibitor-1) and inflammation (interleukin (IL)-6, terminal complement complex (sC5b-9)). Comparison of patients stratified according to the presence or absence of overt DIC (International Society of Thrombosis and Hemostasis (ISTH) criteria) or ACoTS (activated partial thromboplastin time (APTT) and/or international normalized ratio (INR) above normal reference).

Results

No patients had overt DIC whereas 15% had ACoTS. ACoTS patients had higher ISS, transfusion requirements and mortality (all P < 0.01) and a biomarker profile suggestive of enhanced tissue, endothelial cell and glycocalyx damage and consumption coagulopathy with low protein C, antithrombin, fibrinogen and FXIII levels, hyperfibrinolysis and inflammation (all P < 0.05). Importantly, in non-ACoTS patients, apart from APTT/INR, higher ISS correlated with biomarkers of enhanced tissue, endothelial cell and glycocalyx damage, protein C activation, coagulation factor consumption, hyperfibrinolysis and inflammation, that is, resembling that observed in patients with ACoTS.

Conclusions

ACoTS and non-ACoTS may represent a continuum of coagulopathy reflecting a progressive early evolutionarily adapted hemostatic response to the trauma hit and both are parts of TIC whereas DIC does not appear to be part of this early response.
Appendix
Available only for authorised users
Literature
1.
Peden M, McGee K, Krug E: Injury: A Leading Cause of the Global Burden of Disease, 2000. Edited by: Peden M, McGee K, Krug E. 2002, Geneva, Switzerland: World Health Organization
2.
Sauaia A, Moore FA, Moore EE, Moser KS, Brennan R, Read RA, Pons PT: Epidemiology of trauma deaths: a reassessment. J Trauma. 1995, 38: 185-193. 10.1097/00005373-199502000-00006.CrossRefPubMed
3.
Sauaia A, Moore FA, Moore EE, Haenel JB, Read RA, Lezotte DC: Early predictors of postinjury multiple organ failure. Arch Surg. 1994, 129: 39-45.CrossRefPubMed
4.
Hess JR, Brohi K, Dutton RP, Hauser CJ, Holcomb JB, Kluger Y, Mackway-Jones K, Parr MJ, Rizoli SB, Yukioka T, Hoyt DB, Bouillon B: The coagulopathy of trauma: a review of mechanisms. J Trauma. 2008, 65: 748-754. 10.1097/TA.0b013e3181877a9c.CrossRefPubMed
5.
Carroll RC, Craft RM, Langdon RJ, Clanton CR, Snider CC, Wellons DD, Dakin PA, Lawson CM, Enderson BL, Kurek SJ: Early evaluation of acute traumatic coagulopathy by thrombelastography. Transl Res. 2009, 154: 34-39. 10.1016/j.trsl.2009.04.001.CrossRefPubMed
6.
Floccard B, Rugeri L, Faure A, Denis MS, Boyle EM, Peguet O, Levrat A, Guillaume C, Marcotte G, Vulliez A, Hautin E, David JS, Negrier C, Allaouchiche B: Early coagulopathy in trauma patients: an on-scene and hospital admission study. Injury. 2010,
7.
Frith D, Brohi K: The acute coagulopathy of trauma shock: Clinical relevance. Surgeon. 2010, 8: 159-163. 10.1016/j.surge.2009.10.022.CrossRefPubMed
8.
Gando S, Sawamura A, Hayakawa M: Trauma, shock, and disseminated intravascular coagulation: lessons from the classical literature. Ann Surg. 2011, 254: 10-19. 10.1097/SLA.0b013e31821221b1.CrossRefPubMed
9.
Bluth MH, Kashuk JL: Mechanistic links in trauma-induced coagulopathy: a tale of two cities. Ann Surg. 2011, 254: 20-21. 10.1097/SLA.0b013e318221be0f.CrossRefPubMed
10.
Gando S: Acute coagulopathy of trauma shock and coagulopathy of trauma: a rebuttal. You are now going down the wrong path. J Trauma. 2009, 67: 381-383. 10.1097/TA.0b013e3181a84f63.CrossRefPubMed
11.
Hayakawa M, Sawamura A, Gando S, Kubota N, Uegaki S, Shimojima H, Sugano M, Ieko M: Disseminated intravascular coagulation at an early phase of trauma is associated with consumption coagulopathy and excessive fibrinolysis both by plasmin and neutrophil elastase. Surgery. 2011, 149: 221-230. 10.1016/j.surg.2010.06.010.CrossRefPubMed
12.
Sawamura A, Hayakawa M, Gando S, Kubota N, Sugano M, Wada T, Katabami KI: Disseminated intravascular coagulation with a fibrinolytic phenotype at an early phase of trauma predicts mortality. Thromb Res. 2009, 124: 608-613. 10.1016/j.thromres.2009.06.034.CrossRefPubMed
13.
Brohi K, Cohen MJ, Davenport RA: Acute coagulopathy of trauma: mechanism, identification and effect. Curr Opin Crit Care. 2007, 13: 680-685. 10.1097/MCC.0b013e3282f1e78f.CrossRefPubMed
14.
Brohi K, Cohen MJ, Ganter MT, Schultz MJ, Levi M, Mackersie RC, Pittet JF: Acute coagulopathy of trauma: hypoperfusion induces systemic anticoagulation and hyperfibrinolysis. J Trauma. 2008, 64: 1211-1217. 10.1097/TA.0b013e318169cd3c.CrossRefPubMed
15.
Brohi K, Cohen MJ, Ganter MT, Matthay MA, Mackersie RC, Pittet JF: Acute traumatic coagulopathy: initiated by hypoperfusion: modulated through the protein C pathway?. Ann Surg. 2007, 245: 812-818. 10.1097/01.sla.0000256862.79374.31.PubMedCentralCrossRefPubMed
16.
Johansson PI, Ostrowski SR: Acute coagulopathy of trauma: balancing progressive catecholamine induced endothelial activation and damage by fluid phase anticoagulation. Med Hypotheses. 2010, 75: 564-567. 10.1016/j.mehy.2010.07.031.CrossRefPubMed
17.
Johansson PI, Stensballe J, Rasmussen LS, Ostrowski SR: A high admission syndecan-1 level, a marker of endothelial glycocalyx degradation, is associated with inflammation, protein C depletion, fibrinolysis, and increased mortality in trauma patients. Ann Surg. 2011, 254: 194-200. 10.1097/SLA.0b013e318226113d.CrossRefPubMed
18.
Taylor FB, Toh CH, Hoots WK, Wada H, Levi M: Towards definition, clinical and laboratory criteria, and a scoring system for disseminated intravascular coagulation. Thromb Haemost. 2001, 86: 1327-1330.PubMed
19.
Kienast J, Juers M, Wiedermann CJ, Hoffmann JN, Ostermann H, Strauss R, Keinecke HO, Warren BL, Opal SM: Treatment effects of high-dose antithrombin without concomitant heparin in patients with severe sepsis with or without disseminated intravascular coagulation. J Thromb Haemost. 2006, 4: 90-97.CrossRefPubMed
20.
Johansson PI, Stensballe J, Rasmussen LS, Ostrowski SR: High circulating adrenaline levels at admission predict increased mortality after trauma. J Trauma. 2011,
21.
Lustenberger T, Talving P, Kobayashi L, Barmparas G, Inaba K, Lam L, Branco BC, Demetriades D: Early coagulopathy after isolated severe traumatic brain injury: relationship with hypoperfusion challenged. J Trauma. 2010, 69: 1410-1414. 10.1097/TA.0b013e3181cdae81.CrossRefPubMed
22.
Dunbar NM, Chandler WL: Thrombin generation in trauma patients. Transfusion. 2009, 49: 2652-2660. 10.1111/j.1537-2995.2009.02335.x.CrossRefPubMed
23.
Shaz BH, Winkler AM, James AB, Hillyer CD, MacLeod JB: Pathophysiology of early trauma-induced coagulopathy: emerging evidence for hemodilution and coagulation factor depletion. J Trauma. 2011, 70: 1401-1407. 10.1097/TA.0b013e31821266e0.PubMedCentralCrossRefPubMed
24.
Kannemeier C, Shibamiya A, Nakazawa F, Trusheim H, Ruppert C, Markart P, Song Y, Tzima E, Kennerknecht E, Niepmann M, von Bruehl ML, Sedding D, Massberg S, Gunther A, Engelmann B, Preissner KT: Extracellular RNA constitutes a natural procoagulant cofactor in blood coagulation. Proc Natl Acad Sci USA. 2007, 104: 6388-6393. 10.1073/pnas.0608647104.PubMedCentralCrossRefPubMed
25.
Rehm M, Bruegger D, Christ F, Conzen P, Thiel M, Jacob M, Chappell D, Stoeckelhuber M, Welsch U, Reichart B, Peter K, Becker BF: Shedding of the endothelial glycocalyx in patients undergoing major vascular surgery with global and regional ischemia. Circulation. 2007, 116: 1896-1906. 10.1161/CIRCULATIONAHA.106.684852.CrossRefPubMed
26.
Becker BF, Chappell D, Bruegger D, Annecke T, Jacob M: Therapeutic strategies targeting the endothelial glycocalyx: acute deficits, but great potential. Cardiovasc Res. 2010, 87: 300-310. 10.1093/cvr/cvq137.CrossRefPubMed
27.
Chakroun T, Gerotziafas GT, Seghatchian J, Samama MM, Hatmi M, Elalamy I: The influence of fibrin polymerization and platelet-mediated contractile forces on citrated whole blood thromboelastography profile. Thromb Haemost. 2006, 95: 822-828.PubMed
28.
Shen L, Lorand L: Contribution of fibrin stabilization to clot strength. Supplementation of factor XIII-deficient plasma with the purified zymogen. J Clin Invest. 1983, 71: 1336-1341. 10.1172/JCI110885.PubMedCentralCrossRefPubMed
29.
Johansson PI, Jacobsen N, Viuff D, Olsen EH, Rojkjaer R, Andersen S, Petersen LC, Kjalke M: Differential clot stabilising effects of rFVIIa and rFXIII-A in whole blood from thrombocytopenic patients and healthy volunteers. Br J Haematol. 2008, 143: 559-569.PubMed
30.
Gando S: Disseminated intravascular coagulation in trauma patients. Semin Thromb Hemost. 2001, 27: 585-592. 10.1055/s-2001-18864.CrossRefPubMed
Metadata
Title
Disseminated intravascular coagulation or acute coagulopathy of trauma shock early after trauma? An observational study
Authors
Pär I Johansson
Anne Marie Sørensen
Anders Perner
Karen Lise Welling
Michael Wanscher
Claus F Larsen
Sisse R Ostrowski
Publication date
01-12-2011
Publisher
BioMed Central
Published in
Critical Care / Issue 6/2011
Electronic ISSN: 1364-8535
DOI
https://doi.org/10.1186/cc10553

Other articles of this Issue 6/2011

Critical Care 6/2011 Go to the issue

Commentary

The good and the bad of diabetes mellitus in the critically ill

Commentary

Lactate in the critically ill patients: an outcome marker with the times

Research

Reduction in hospital-wide mortality after implementation of a rapid response team: a long-term cohort study

Journal club critique

Quality in quality improvement research - a new benchmark

Commentary

Probiotics for severe trauma patients

Commentary

Why high suPAR is not super - diagnostic, prognostic and potential pathogenic properties of a novel biomarker in the ICU