scholarly journals Tools to predict acute traumatic coagulopathy in the pre-hospital setting: a review of the literature

2020 ◽  
Vol 5 (3) ◽  
pp. 23-30
Author(s):  
Simon Robinson ◽  
Jordan Kirton
Keyword(s):  
Major Trauma ◽  
Point Of Care ◽  
Damage Control ◽  
Hospital Setting ◽  
Future Research ◽  
Blood Products ◽  
Point Of Care Testing ◽  
Acute Traumatic Coagulopathy ◽  
Prediction Tools ◽  
Traumatic Coagulopathy

<sec id="s1">Introduction: Recognising acute traumatic coagulopathy (ATC) poses a significant challenge to improving survival in emergency care. Paramedics are in a prime position to identify ATC in pre-hospital major trauma and initiate appropriate coagulopathy management. </sec> <sec id="s2">Method: A database literature review was conducted using Scopus, CINAHL and MEDLINE. </sec> <sec id="s3">Results: Two themes were identified from four studies: prediction tools, and point-of-care testing. Prediction tools identified key common ATC markers in the pre-hospital setting, including: systolic blood pressure, reduced Glasgow Coma Score and trauma to the chest, abdomen and pelvis. Point-of-care testing was found to have limited value. </sec> <sec id="s4">Conclusion: Future research needs to explore paramedics using prediction tools in identifying ATC, which could alert hospitals to prepare for blood products for damage control resuscitation. </sec>

scholarly journals Activated Protein C Drives the Hyperfibrinolysis of Acute Traumatic Coagulopathy

2017 ◽  
Vol 126 (1) ◽  
pp. 115-127 ◽  
Author(s):  
Ross A. Davenport ◽  
Maria Guerreiro ◽  
Daniel Frith ◽  
Claire Rourke ◽  
Sean Platton ◽  
...  
Keyword(s):  
Murine Model ◽  
Protein C ◽  
Major Trauma ◽  
Activated Protein C ◽  
Genetic Mutation ◽  
Trauma Patients ◽  
Acute Traumatic Coagulopathy ◽  
Rotational Thromboelastometry ◽  
Level 1 Trauma Center ◽  
Traumatic Coagulopathy

Abstract Background Major trauma is a leading cause of morbidity and mortality worldwide with hemorrhage accounting for 40% of deaths. Acute traumatic coagulopathy exacerbates bleeding, but controversy remains over the degree to which inhibition of procoagulant pathways (anticoagulation), fibrinogen loss, and fibrinolysis drive the pathologic process. Through a combination of experimental study in a murine model of trauma hemorrhage and human observation, the authors’ objective was to determine the predominant pathophysiology of acute traumatic coagulopathy. Methods First, a prospective cohort study of 300 trauma patients admitted to a single level 1 trauma center with blood samples collected on arrival was performed. Second, a murine model of acute traumatic coagulopathy with suppressed protein C activation via genetic mutation of thrombomodulin was used. In both studies, analysis for coagulation screen, activated protein C levels, and rotational thromboelastometry (ROTEM) was performed. Results In patients with acute traumatic coagulopathy, the authors have demonstrated elevated activated protein C levels with profound fibrinolytic activity and early depletion of fibrinogen. Procoagulant pathways were only minimally inhibited with preservation of capacity to generate thrombin. Compared to factors V and VIII, proteases that do not undergo activated protein C–mediated cleavage were reduced but maintained within normal levels. In transgenic mice with reduced capacity to activate protein C, both fibrinolysis and fibrinogen depletion were significantly attenuated. Other recognized drivers of coagulopathy were associated with less significant perturbations of coagulation. Conclusions Activated protein C–associated fibrinolysis and fibrinogenolysis, rather than inhibition of procoagulant pathways, predominate in acute traumatic coagulopathy. In combination, these findings suggest a central role for the protein C pathway in acute traumatic coagulopathy and provide new translational opportunities for management of major trauma hemorrhage.

scholarly journals Early Identification of Acute Traumatic Coagulopathy Using Clinical Prediction Tools: A Systematic Review

Medicina ◽  
2019 ◽  
Vol 55 (10) ◽  
pp. 653 ◽  
Author(s):  
Thorn ◽  
Güting ◽  
Maegele ◽  
Gruen ◽  
Mitra
Keyword(s):  
Systematic Review ◽  
Blood Pressure ◽  
Prediction Models ◽  
Scoring Systems ◽  
Trauma Patients ◽  
Clinical Prediction ◽  
Acute Traumatic Coagulopathy ◽  
Prediction Tools ◽  
Populations At Risk ◽  
Traumatic Coagulopathy

: Background and objectives: Prompt identification of patients with acute traumatic coagulopathy (ATC) is necessary to expedite appropriate treatment. An early clinical prediction tool that does not require laboratory testing is a convenient way to estimate risk. Prediction models have been developed, but none are in widespread use. This systematic review aimed to identify and assess accuracy of prediction tools for ATC. Materials and Methods: A search of OVID Medline and Embase was performed for articles published between January 1998 and February 2018. We searched for prognostic and predictive studies of coagulopathy in adult trauma patients. Studies that described stand-alone predictive or associated factors were excluded. Studies describing prediction of laboratory-diagnosed ATC were extracted. Performance of these tools was described. Results: Six studies were identified describing four different ATC prediction tools. The COAST score uses five prehospital variables (blood pressure, temperature, chest decompression, vehicular entrapment and abdominal injury) and performed with 60% sensitivity and 96% specificity to identify an International Normalised Ratio (INR) of >1.5 on an Australian single centre cohort. TICCS predicted an INR of >1.3 in a small Belgian cohort with 100% sensitivity and 96% specificity based on admissions to resuscitation rooms, blood pressure and injury distribution but performed with an Area under the Receiver Operating Characteristic (AUROC) curve of 0.700 on a German trauma registry validation. Prediction of Acute Coagulopathy of Trauma (PACT) was developed in USA using six weighted variables (shock index, age, mechanism of injury, Glasgow Coma Scale, cardiopulmonary resuscitation, intubation) and predicted an INR of >1.5 with 73.1% sensitivity and 73.8% specificity. The Bayesian network model is an artificial intelligence system that predicted a prothrombin time ratio of >1.2 based on 14 clinical variables with 90% sensitivity and 92% specificity. Conclusions: The search for ATC prediction models yielded four scoring systems. While there is some potential to be implemented effectively in clinical practice, none have been sufficiently externally validated to demonstrate associations with patient outcomes. These tools remain useful for research purposes to identify populations at risk of ATC.

Impact of Cardiac Point-of-care Testing on ED Door to Disposition Time is Dependent on Patient Acuity and Hospital Setting

2007 ◽  
Vol 14 (5 Supplement 1) ◽  
pp. S130-S130
Author(s):  
G. Fermann ◽  
C. Lindsell ◽  
R. Rohlfing ◽  
J. Deledda ◽  
B. Gibler
Keyword(s):  
Point Of Care ◽  
Hospital Setting ◽  
Point Of Care Testing ◽  
Patient Acuity ◽  
Disposition Time

scholarly journals P145: HIV point of care testing by community paramedics in a vulnerable population: a pilot study

CJEM ◽  
2016 ◽  
Vol 18 (S1) ◽  
pp. S126-S126 ◽  
Author(s):  
H. Yaworski ◽  
P. Hutlet ◽  
R. Grierson ◽  
E. Weldon ◽  
R. Sneath ◽  
...  
Keyword(s):  
Inner City ◽  
Hiv Testing ◽  
Large Scale ◽  
Point Of Care ◽  
Future Research ◽  
Point Of Care Testing ◽  
Post Test ◽  
Study Population ◽  
The Mean ◽  
Age Range

Introduction: Literature suggests that up to 25% of people with HIV in North America are unaware of their status and are at risk to transmit the virus unknowingly. A high proportion of HIV patients are diagnosed when the disease is more advanced, with CD4 counts < 200. This study examined the rates of HIV testing, detection, and treatment of clients at an inner city shelter and detoxification centre after the introduction of a point of care testing (POCT) program by on-site community paramedics (CP). Methods: In 2013, in collaboration with a regional HIV program, CP received training and instituted an HIV POCT program and post-test counselling initiative. A retrospective electronic database review from October 16, 2013 to October 15, 2014 of adult patients who received testing was performed. Demographic and testing details of each patient encounter were abstracted and select variables were compared to a historic population who received POC HIV testing at an inner city emergency department (ED) in the same city. Results: 1,207 HIV POC tests were performed on 997 patients during the pilot. 57% of the patients tested were less than 40 years of age (range 18-73 years) compared to 55% in the historic ED population. A total of 9 reactive cases were identified in the study population including 3 new cases, 5 previously known cases, and 1 false reactive result. The mean age of the new cases was 47 years, vs 44 in the historical control. All 3 new cases were referred to a local HIV clinic for further care and treatment. New HIV cases represented 0.25% of total tests performed, which is less than the expected prevalence rate of 1% for this population, as well as the rate of 1.4% found in the ED population. Conclusion: Despite lower than expected reactive rates, the large scale implementation of a CP HIV POCT program in an inner city shelter and detoxification centre is feasible. All patients with new reactive tests were immediately connected to care. Future research will focus on risk factors and barriers to testing.

Evaluation of a Novel Transfusion Algorithm Employing Point-of-care Coagulation Assays in Cardiac Surgery

2015 ◽  
Vol 122 (3) ◽  
pp. 560-570 ◽  
Author(s):  
Keyvan Karkouti ◽  
Stuart A. McCluskey ◽  
Jeannie Callum ◽  
John Freedman ◽  
Rita Selby ◽  
...  
Keyword(s):  
Cardiac Surgery ◽  
Time Trends ◽  
Point Of Care ◽  
Interrupted Time Series ◽  
Blood Products ◽  
Interrupted Time Series Analysis ◽  
Point Of Care Testing ◽  
Coagulation Testing ◽  
Coagulation Tests ◽  
The Many

Abstract Background: Cardiac surgery requiring the use of cardiopulmonary bypass is frequently complicated by coagulopathic bleeding that, largely due to the shortcomings of conventional coagulation tests, is difficult to manage. This study evaluated a novel transfusion algorithm that uses point-of-care coagulation testing. Methods: Consecutive patients who underwent cardiac surgery with bypass at one hospital before (January 1, 2012 to January 6, 2013) and after (January 7, 2013 to December 13, 2013) institution of an algorithm that used the results of point-of-care testing (ROTEM®; Tem International GmBH, Munich, Germany; Plateletworks®; Helena Laboratories, Beaumont, TX) during bypass to guide management of coagulopathy were included. Pre- and postalgorithm outcomes were compared using interrupted time-series analysis to control for secular time trends and other confounders. Results: Pre- and postalgorithm groups included 1,311 and 1,170 patients, respectively. Transfusion rates for all blood products (except for cryoprecipitate, which did not change) were decreased after algorithm institution. After controlling for secular pre- and postalgorithm time trends and potential confounders, the posttransfusion odds ratios (95% CIs) for erythrocytes, platelets, and plasma were 0.50 (0.32 to 0.77), 0.22 (0.13 to 0.37), and 0.20 (0.12 to 0.34), respectively. There were no indications that the algorithm worsened any of the measured processes of care or outcomes. Conclusions: Institution of a transfusion algorithm based on point-of-care testing was associated with reduced transfusions. This suggests that the algorithm could improve the management of the many patients who develop coagulopathic bleeding after cardiac surgery. The generalizability of the findings needs to be confirmed.

A Prospective Evaluation of Acute Traumatic Coagulopathy and Effects of Damage Control Resuscitation in Military Trauma Patients in Afghanistan

Blood ◽  
2014 ◽  
Vol 124 (21) ◽  
pp. 2848-2848
Author(s):  
Zachary Edward Wright ◽  
Ian Stewart ◽  
Jonathan Sosnov ◽  
Heather F Pidcoke ◽  
Fedyk Chriselda ◽  
...  
Keyword(s):  
High Risk ◽  
Conflicts Of Interest ◽  
Damage Control ◽  
Trauma Patients ◽  
Damage Control Resuscitation ◽  
Acute Traumatic Coagulopathy ◽  
Transfusion Requirements ◽  
Severity Scores ◽  
Over Time ◽  
Traumatic Coagulopathy

Abstract Hemorrhage remains the leading cause of preventable morality, resulting in the death of over a third of all trauma patients. Additionally, twenty-five percent of trauma patients present on admission with acute traumatic coagulopathy (ATC) which portends a mortality approaching fifty percent. ATC has been defined by multiple parameters including international normalized ratio (INR) >1.2, rotational thromboelastometry (ROTEM) clot amplitude at 5 minutes (CA5) ≤ 35 mm and lysis at 60 minutes (LI60) ≤ 85%. Damage control resuscitation (DCR), the practice of the Joint Theater Trauma System in Iraq and Afghanistan, is based on rapid hemorrhage control, permissive hypotension and transfusion of blood products in a ratio that aims to deliver the functionality of whole blood (1:1:1, red cells:plasma:platelets), in addition to limiting crystalloid resuscitation. ROTEM defined ATC has not been observed over time among DCR eligible combat casualties. The goal of this study was to identify ATC and the effects of DCR in trauma patients treated at level III trauma hospitals in Afghanistan. In this prospective observational study, 88 trauma patients were treated at Craig Air Force Theatre Hospital – Bagram, or Kandahar NATO Hospital in the Afghanistan Theatre. We included only patients from coalition forces identified as having injury that would result in the loss of life or total disability resulting in activation of DCR. Blood was obtained for analysis upon admission and at 6 and 24 hours after admission by a designated research team. Blood was analyzed by ROTEM with multiple assays (EXTEM, FIBTEM, APTEM); however, data was not available to the treatment team. Complete blood counts and INR were also obtained and Injury Severity Scores (ISS) were determined. Transfusion requirements of red blood cells (RBCs), platelets (PLT), fresh frozen plasma (FFP) and cryoprecipitate were recorded for the first 24 hours following admission. ROTEM changes over time were analyzed using Wilcoxon signed-rank test. Forty patients in the cohort had ROTEM (EXTEM) data obtained for evaluation as equipment was unavailable during a portion of the study. The median ISS was 21.5 (IQR 14-27). Four of the patients in the cohort died. The median admission hemoglobin and hematocrit were 11.1 g/dL (IQR 10.1-12) and 32.3% (IQR 29-34.5) respectively. The median INR was 1.3 (IQR 1.2-1.4). The median patient RBC to FFP to PLT ratio was 1:1:0.8. The median clot time (CT) and maximum clot firmness (MCF) were 58.5 sec (IQR 51-65.5) and 56 mm (IQR 51-60.5) respectively. Median CA5 was 37.5 mm (IQR 31-45). ATC as identified by CA5 ≤ 35 mm was present in 15 of 40 patients (38%) upon admission. The median CA5 of patients who met criteria for ATC on admission was 26 mm (IQR 15-34) which improved to 38 mm (IQR 33-44) at 24 hours (p < 0.01). Median LI45 was 98% (IQR 96-99). Hyperfibrinolysis as defined by LI45 ≤ 85% was observed in 4 of 40 patients (10%) upon admission which did not change significantly at 24 hours. The incidence of acute traumatic coagulopathy as defined by ROTEM parameters in this high risk military cohort appears to be higher compared to that reported for civilian populations. These data suggest that current DCR practices including a 1:1:1 RBC:FFP:PLT ratio appropriately target high risk trauma patients with ATC and that this strategy appears to be associated with a reduction in the burden of coagulopathy by 24 hours. Disclosures No relevant conflicts of interest to declare.

Massive transfusion in paediatric trauma: a single centre experience

2010 ◽  
Vol 27 (Suppl 1) ◽  
pp. A10.3-A11
Author(s):  
Robert Hearn
Keyword(s):  
Emergency Department ◽  
Major Trauma ◽  
Massive Transfusion ◽  
Damage Control ◽  
Penetrating Trauma ◽  
Damage Control Surgery ◽  
Blood Parameters ◽  
Major Haemorrhage ◽  
Blood Products ◽  
Paediatric Trauma

AimsTo report the occurrence of major haemorrhage in children following major trauma, the practice of blood products transfusion including monitoring of laboratory parameters in such patients and the outcomes.MethodsWe retrospectively analysed the local paediatric trauma database of all children following trauma call activation on arrival to the Emergency Department in a major urban trauma centre in London. We studies over a period of 15 months, May 2008–August 2009. We defined massive transfusion as packed red cells >40 ml/kg in the first 4 h or >80 ml/kg in the first 24 h.Results227 children presented to the accidents and emergency during this period following major trauma call activation. The median age at presentation was 10.2 years. 13 (5.7%) children had major haemorrhage. The median ISS WAS 35 (IQR 10–60). All but one were males. Three had penetrating trauma, one of whom made it to theatre but all died. Four had emergency damage control surgery. Abnormal results were seen in three patients, each having one abnormal result (INR=1.9 and APTT=86, low Hb=7.6, thrombocytopaenia =63). 8/13 patients received additional blood products such as Fresh Frozen Plasma (FFP), platelets and Cryoprecipitate. However, no patient received the ration of blood products RBC:FFP of 1:1 as practised in adult trauma. Two patients had no admission bloods done. Worsening coagulation parameters were seen in two patients when measure post-transfusion and the remaining 11 patients did not have routine monitoring of blood parameters post-transfusion. 8 (62%) patients died of which 7 died in the Emergency Department.ConclusionsMajor haemorrhage is associated with a very high mortality in severely injured children. There is a need for instituting a major haemorrhage policy in paediatric trauma and consideration of point-of-care testing of blood parameters.

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