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

Ronald Chang, Erin E. Fox, Thomas J. Greene, Michael D. Swartz, Stacia M. DeSantis, Deborah M. Stein, Eileen M. Bulger, Sherry M. Melton, Michael D. Goodman, Martin A. Schreiber, Martin D. Zielinski, Terence S Okeeffe, Kenji Inaba, Jeffrey S. Tomasek, Jeanette M. Podbielski, Savitri Appana, Misung Yi, Pär I. Johansson, Hanne H. Henriksen, Jakob StensballeJacob Steinmetz, Charles E. Wade, Peter M Rhee

Research output: Contribution to journalArticle

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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. (Surgery 2017;160:XXX-XXX.).

Original languageEnglish (US)
JournalSurgery (United States)
DOIs
StateAccepted/In press - Jan 1 2017

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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

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Abnormalities of laboratory coagulation tests versus clinically evident coagulopathic bleeding : Results from the prehospital resuscitation on helicopters study (PROHS). / Chang, Ronald; Fox, Erin E.; Greene, Thomas J.; Swartz, Michael D.; DeSantis, Stacia M.; Stein, Deborah M.; Bulger, Eileen M.; Melton, Sherry M.; Goodman, Michael D.; Schreiber, Martin A.; Zielinski, Martin D.; Okeeffe, Terence S; Inaba, Kenji; Tomasek, Jeffrey S.; Podbielski, Jeanette M.; Appana, Savitri; Yi, Misung; Johansson, Pär I.; Henriksen, Hanne H.; Stensballe, Jakob; Steinmetz, Jacob; Wade, Charles E.; Rhee, Peter M.

In: Surgery (United States), 01.01.2017.

Research output: Contribution to journalArticle

Chang, R, Fox, EE, Greene, TJ, Swartz, MD, DeSantis, SM, Stein, DM, Bulger, EM, Melton, SM, Goodman, MD, Schreiber, MA, Zielinski, MD, Okeeffe, TS, Inaba, K, Tomasek, JS, Podbielski, JM, Appana, S, Yi, M, Johansson, PI, Henriksen, HH, Stensballe, J, Steinmetz, J, Wade, CE & Rhee, PM 2017, 'Abnormalities of laboratory coagulation tests versus clinically evident coagulopathic bleeding: Results from the prehospital resuscitation on helicopters study (PROHS)', Surgery (United States). https://doi.org/10.1016/j.surg.2017.10.050
Chang, Ronald ; Fox, Erin E. ; Greene, Thomas J. ; Swartz, Michael D. ; DeSantis, Stacia M. ; Stein, Deborah M. ; Bulger, Eileen M. ; Melton, Sherry M. ; Goodman, Michael D. ; Schreiber, Martin A. ; Zielinski, Martin D. ; Okeeffe, Terence S ; Inaba, Kenji ; Tomasek, Jeffrey S. ; Podbielski, Jeanette M. ; Appana, Savitri ; Yi, Misung ; Johansson, Pär I. ; Henriksen, Hanne H. ; Stensballe, Jakob ; Steinmetz, Jacob ; Wade, Charles E. ; Rhee, Peter M. / Abnormalities of laboratory coagulation tests versus clinically evident coagulopathic bleeding : Results from the prehospital resuscitation on helicopters study (PROHS). In: Surgery (United States). 2017.
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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. (Surgery 2017;160:XXX-XXX.).",
author = "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 Okeeffe, {Terence S} and Kenji Inaba 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 Rhee, {Peter M}",
year = "2017",
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TY - JOUR

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

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

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 - Okeeffe, Terence S

AU - Inaba, Kenji

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 - Rhee, Peter M

PY - 2017/1/1

Y1 - 2017/1/1

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. (Surgery 2017;160:XXX-XXX.).

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. (Surgery 2017;160:XXX-XXX.).

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U2 - 10.1016/j.surg.2017.10.050

DO - 10.1016/j.surg.2017.10.050

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