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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 12  |  Issue : 1  |  Page : 26-30

Study of coagulation profile in patients admitted to a trauma center in a tertiary care hospital


Department of Pathology, B. J. Government Medical College, Pune, Maharashtra, India

Date of Submission26-Aug-2020
Date of Decision16-Oct-2020
Date of Acceptance08-Dec-2020
Date of Web Publication15-Mar-2021

Correspondence Address:
Dr. Anup Pravin Bhandari
A-304, Dreams Onella, Satavnagar, Handewadi Road, Hadapsar, Pune - 411 028, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/joah.joah_151_20

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  Abstract 

CONTEXT: Globally, trauma is the leading cause of death in young adult population, with approximately accounting for 10% of all deaths. Trauma-induced coagulopathy (TIC) is an independent predictor of morbidity and mortality.
AIMS: The aim of the study was to find the prevalence of abnormal test results of coagulation on admission to a trauma center and correlate them with mortality.
SETTINGS AND DESIGN: This was a cross-sectional observational study conducted on patients admitted to a trauma center of a tertiary care hospital.
SUBJECTS AND METHODS: A total of 149 patients with an Injury Severity Score >15 were included in the study. Blood samples of the patients were collected within 24 h of trauma and 2 h of admission and tested for platelet (PLT) count, prothrombin time (PT), activated partial thromboplastin time (APTT), and fibrinogen (FIB) level. The patients were stratified into two groups – presence/absence of TIC and followed for 2 weeks for mortality.
STATISTICAL ANALYSIS USED: Data analysis was done using Microsoft Excel and statistics software SPSS 20 version.
RESULTS: Among the 149 patients, 84 had TIC, out of which 71.43% of the patients showed mortality. Of the remaining patients who had no TIC, 35.38% reported mortality. If all the four parameters, that is, PT, APTT, FIB, and PLTs, were considered together, then the percentage of mortality increased to 89.47%. If PT and APTT were studied together, then the percentage of mortality increased to 85.71%. If PT, APTT, and FIB were studied together, the mortality was 84.62%, whereas for parameters PT, APTT, and PLTs together, the mortality was 80%.
CONCLUSIONS: Coagulopathy is a strong predictor of mortality in major trauma patients. Basic coagulation tests appear to be sensitive tools for identifying patients at high risk of early death and can be used for early minute diagnosis of TIC. Patients with TIC should be managed aggressively to prevent mortality.

Keywords: Activated partial thromboplastin time, Injury Severity Score, prothrombin time, trauma-induced coagulopathy


How to cite this article:
Kulkarni KK, Bhandari AP, Rathod P. Study of coagulation profile in patients admitted to a trauma center in a tertiary care hospital. J Appl Hematol 2021;12:26-30

How to cite this URL:
Kulkarni KK, Bhandari AP, Rathod P. Study of coagulation profile in patients admitted to a trauma center in a tertiary care hospital. J Appl Hematol [serial online] 2021 [cited 2021 Apr 15];12:26-30. Available from: https://www.jahjournal.org/text.asp?2021/12/1/26/311335


  Introduction Top


The Vietnam War first highlighted the role of coagulopathic process in severe trauma.[1] A lot of patients with multi-trauma develop an early trauma-induced coagulopathy (TIC), which is also known as acute traumatic coagulopathy (ATC). Coagulopathy of trauma or TIC is defined as a syndrome of nonsurgical bleeding from mucosal lesions, serosal surfaces, wound, and vascular access sites, associated with serious physical traumatic injury, accompanied by hypothermia, acidosis, hemodilution and occasionally with consumption of coagulation factors as well as fibrinolysis.[2] Coagulopathy often needs massive transfusion as treatment and is one of the strongest predictors of mortality.

Trauma severity strongly correlates with mortality, morbidity, and hospitalization time after trauma and to objectively assess severity, the Injury Severity Score (ISS), an established medical score, is often used.[3],[4]

A major trauma or polytrauma is defined as the ISS being >15.[4] It has been observed that patients with ISS of 25 or higher, hypothermia, and acidosis are always coagulopathic and have a mortality rate higher than that of noncoagulopathic (nonhypothermic and nonacidotic) patients with similar injuries.[5],[6]

Brohi's group defined the presence of significant coagulopathy upon arrival at a trauma-receiving unit (TRU) as prothrombin time (PT) >18 s (1.5 times normal) and activated partial thromboplastin time (APTT) >60 s (twice normal).[7] Similarly, MacLeod's group used platelet (PLT) count of <100 × 109 cells/L as evidence of coagulopathy. Trauma patients also show acquired fibrinogen (FIB) deficiency and their blood levels on admission strongly correlate with hemodynamic shock and the severity of injury.[6],[8]

The present study was undertaken to evaluate coagulation profile consisting of PT, APTT, PLT, and FIB levels in acute polytrauma patients admitted in the TRU of a tertiary care hospital and to correlate them with mortality.


  Subjects and Methods Top


This hospital-based, cross-sectional, observational study was conducted on patients admitted in the TRU of a tertiary care hospital from January 2017 to June 2018 after institutional ethical committee clearance.

Inclusion criteria were all patients >14 years of age admitted directly from the scene of injury to the trauma center of the tertiary care unit and having ISSs >15. Samples were collected before resuscitation began with an acceptable timeframe of 24 h of trauma and 2 h of admission. Patients transferred from other institutions, readmission cases, previous transfusion cases, nontrauma patients, patients with a history of any coagulation disorder or diseases with abnormal coagulation tests, and patients with chronic injury were excluded from the study.

The study protocol included a detailed clinical examination record of patients along with the calculation of ISS.[3] Patients with ISS >15 were selected for sample collection. After taking written direct or indirect consent, blood sample was obtained by standard venipuncture method under aseptic precautions.[9] For PLT and FIB assay, sample was collected in an EDTA bulb, while for PT and APTT, sample was collected in a citrate bulb up to the given mark.

PT and APTT measurement was done using a semi-automated Hemostar XF 2.0 analyzer (Tulip Diagnostics, Verna, Goa, India) which is based on the optomechanical clot detection principle. PLT count was obtained by ERMA PCE-210 automated hematology analyzer, AGD Biomedical Pvt. Ltd., Mumbai, India. which uses Coulter's principle. FIB assay was performed by precipitation method using sodium sulfite followed by measurement of optical density by a colorimeter at 630 nm. FIB concentration in mg% was obtained using standard calculations.[10]

Brohi's group criteria (PT >18 s and/or APTT >60 s) were used to define TIC, and patients were divided into two groups based on the presence or absence of coagulopathy. Other criteria used for the study were Hess and Lawson[2] (FIB level <200 mg/dL) and MacLeod's group (PLT count <1 lakh/mL). All parameters were studied and correlated with mortality.

Data analysis was done using Microsoft Excel and statistics software SPSS 20 version. Manufacturer: IBM, India.

Chi-square test was used for data variables. P value was calculated for statistical significance.


  Results Top


The most common age group involved in trauma cases of our study was 21–30 years (25.5%) with a mean age of 41 years. Male (91.9%) population was predominantly affected [Chart 1]. The types of trauma reported were road traffic accident (RTA), assault, fall, crush injury, electric shock, etc. Out of all, RTA was the most common mode of injury which accounted for 76.5% of trauma [Chart 2].



When PT/international normalized ratio (INR) was studied alone, patients who had abnormal PT (>18 s) or INR (>1.5) had reported higher percentage of mortality (67.12% and 67.02%, respectively). Similarly, when abnormal APTT (>60 s) was studied alone, 89.09% of the patients showed mortality. Patients with low PLT count (<1 lakh/mm3) and deranged FIB value (<200 mg/dL) had 53.76% and 69.74% mortality rate, respectively. Except low PLT count, all other parameters were independently associated with a high mortality rate (P < 0.05).

If TIC prevalence with mortality was compared, the presence of TIC was reported to have a high mortality (71.43%). Mortality increased from 71.43% to 89.47% when all the four parameters were taken into consideration. The mortality was 85.71% when both PT and APTT were deranged. The mortality was 84.62% when PT, APTT, and FIB were deranged, whereas it was 80% when PT, APTT, and PLT were deranged [Table 1].
Table 1: Percentage distribution of deranged laboratory test parameters and associated mortality

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  Discussion Top


Although the epidemiology of traumatic coagulopathy is a known phenomenon, its detailed description is not clear due to varied reports on small to moderately sized cohorts and often highly selected trauma population.[11] The purpose of this study was to report on the prevalence and prognostic significance of abnormalities of the common coagulation tests performed in trauma patients with ISS >15.

Our study comprised a total of 149 patients with a mean age of 41 years. The most common age group studied was 20–30 years. These findings were comparable to those of the study done by Hess et al.[11] As our study had a male predominance (91.9%), it can be said that trauma is more prevalent among males. The most common mode of injury in this study was RTA followed by assault and fall. These findings were consistent with those of studies by Mujuni et al.[12] and Derakhshanfar et al.[13]

The prevalence of TIC (PT >18 s or APTT >60 s) in our study was 56.37%, which is comparable to the findings of Mujuni et al.[12] and Chhabra et al.[14] This prevalence is higher than that reported in few studies which ranged from 28% to 34%. This might be because we included only major trauma patients unlike other studies which consisted of both minor and major trauma patients. [6, 7, 15, 16] The mortality rate among ATC patients was 71.43%, which showed highly significant P value (<0.01). Brohi et al.'s[15] study which used the same criteria of TIC showed nearly comparable mortality (62%), while Mujuni et al.'s[12] study showed 29.3% mortality. The reason for this less mortality might be because the criterion for APTT in TIC was less than that of our study (APTT >36 s).

When considered alone, deranged PT/INR in TIC reported approximately 67% mortality, which again is statistically highly significant (P < 0.01). Only deranged APTT was more significantly associated with mortality (89.09%) than any other parameter. Deranged FIB reported to have 69.74% mortality, while low PLT count reported the least mortality rate of 58.93%. The mortality rate of PLT count alone showed P = 0.611 which was not statistically significant. Therefore, low PLT count alone was not associated with high mortality rate..

Mortality increased from 71.43% to the highest, that is, 98.47%, when all the four parameters were taken into consideration. The mortality was high when both PT and APTT were considered together, that is, 85.71%. Furthermore, if abnormal FIB or PLT was added to PT and APTT, the mortality count was high compared to the criteria of TIC. Hence, increasing the coagulation test parameters at the time of admission will increase predictable in-hospital mortality.

In this study, the average time of incidence of injury to admission was given up to 24 h, compared to <60 min in other studies where well-functioning ambulance system and infrastructure are available.[7] Perhaps, this time delay could be the crucial factor in the high prevalence of coagulopathy and mortality.

In addition, many authors have documented that patients with head trauma have a high prevalence of coagulation abnormalities and mortality.[17],[18] In our study, many of the patients had head injury, which might have contributed to the higher prevalence of TIC.

In our study, most patients were brought by ordinary vehicle cars or by police cars. These transport systems are devoid of first aid and other ambulance facilities, hence patients did not receive any prehospital management. This being a common occurrence in a developing country like India might have contributed to the higher prevalence of TIC.

Finally, these basic coagulation tests appear to be sensitive tools for identifying patients at high risk of early death. These tests are cost-effective and rapidly available in the TRU, but they clearly lack specificity.

Limitation

We included only major trauma patients, while some other studies included all trauma patients. We did not study traumatic brain injury separately.

We have not performed protein C investigation because of unavailability even though implicated as the core mechanism in TIC.

Treatment options such as early provision of fresh frozen plasma, PLT concentrates or FIB, antifibrinolytics, and recombinant factor VIIa have a definite role in reducing mortality, but they were not studied in this study. Additional parameters such as temperature (to detect hypothermia), arterial blood gases (to document metabolic acidosis), and fibrin degradation products would have added valuable information to the pathophysiology of TIC, which were not evaluated in this study.

In recent years, thromboelastography and rotational thromboelastometry (ROTEM) are identified as the best tools for rapid diagnosis of TIC. These tests assess clot strength, fibrinolytic activity, and PLT function.[19],[20] Although ROTEM is considered more reliable than standard coagulation tests, it was not performed in our study due to unavailability.

This study did not address the mechanism of ATC.


  Conclusions Top


Patients having TIC are liable to higher mortality rate than patients without TIC. PT and FIB were found to be the most common abnormal tests among trauma patients, while deranged APTT reported to have the maximum mortality among the four parameters. Except low PLT count, all the other three parameters showed statistically significant P value, hence correlated with higher mortality rate.

The mortality rate increased when all the four parameters were taken into consideration than single or two parameters.

These basic coagulation tests are cost-effective, are rapidly available in TRU, and are sensitive tools for the prediction of unfavorable outcomes. Hence, they should be routinely performed in trauma care practices as diagnostic and prognostic measures. Early intervention is needed in brain trauma patients to prevent mortality.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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2.
Hess JR, Lawson JH. The coagulopathy of trauma versus disseminated intravascular coagulation. J Trauma 2006;60:S12-9.  Back to cited text no. 2
    
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Cosgriff N, Moore EE, Sauaia A, Kenny-Moynihan M, Burch JM, Galloway B. Predicting life-threatening coagulopathy in the massively transfused trauma patient: Hypothermia and acidoses revisited. J Trauma 1997;42:857-61.  Back to cited text no. 5
    
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MacLeod JB, Lynn M, McKenney MG, Cohn SM, Murtha M. Early coagulopathy predicts mortality in trauma. J Trauma 2003;55:39-44.  Back to cited text no. 6
    
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8.
Schlimp CJ, Schöchl H. The role of fibrinogen in trauma-induced coagulopathy. Hamostaseologie 2014;34:29-39.  Back to cited text no. 8
    
9.
World Health Organization. Best practices in phlebotomy. In: WHO Guidelines on Drawing Blood: Best Practices in Phlebotomy. Geneva: World Health Organization; 2010. p. 2. Available from: https://www.ncbi.nlm.nih.gov/books/NBK138665/. [Last accessed on 2020 Jul 28].  Back to cited text no. 9
    
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Goodwin JF. An evaluation of technics for the separation and estimation of plasma fibrinogen. Clin Chem 1965;11:63-73.  Back to cited text no. 10
    
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Hess JR, Lindell AL, Stansbury LG, Dutton RP, Scalea TM. The prevalence of abnormal results of conventional coagulation tests on admission to a trauma center. Transfusion 2009;49:34-9.  Back to cited text no. 11
    
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Mujuni E, Wangoda R, Ongom P, Galukande M. Acute traumatic coagulopathy among major trauma patients in an urban tertiary hospital in sub Saharan Africa. BMC Emerg Med 2012;12:16.  Back to cited text no. 12
    
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Derakhshanfar H, Vafaei A, Tabatabaey A, Noori S. Prevalence and associated factors of acute traumatic coagulopathy; a cross sectional study. Emerg (Tehran) 2017;5:e58.  Back to cited text no. 13
    
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Chhabra G, Sharma S, Subramanian A, Agrawal D, Sinha S, Mukhopadhyay AK. Coagulopathy as prognostic marker in acute traumatic brain injury. J Emerg Trauma Shock 2013;6:180-5.  Back to cited text no. 14
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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;245:812-8.  Back to cited text no. 15
    
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McNamara JJ, Burran EL, Stremple JF, Molot MD. Coagulopathy after major combat injury: Occurrence, management, and pathophysiology. Ann Surg 1972;176:243-6.  Back to cited text no. 16
    
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Cortiana M, Zagara G, Fava S, Seveso M. Coagulation abnormalities in patients with head injury. J Neurosurg Sci 1986;30:133-8.  Back to cited text no. 18
    
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Da Luz LT, Nascimento B, Shankarakutty AK, Rizoli S, Adhikari NK. Effect of thromboelastography (TEG®) and rotational thromboelastometry (ROTEM®) on diagnosis of coagulopathy, transfusion guidance and mortality in trauma: Descriptive systematic review. Crit Care 2014;18:518.  Back to cited text no. 19
    
20.
Hunt H, Stanworth S, Curry N, Woolley T, Cooper C, Ukoumunne O, et al. Thromboelastography (TEG) and rotational thromboelastometry (ROTEM) for trauma induced coagulopathy in adult trauma patients with bleeding. Cochrane Database Syst Rev. 2015;2015(2):CD010438. Published 2015 Feb 16.  Back to cited text no. 20
    



 
 
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