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Clinical presentation and blood gas analysis of multiple trauma patients for prediction of standard coagulation parameters at emergency department arrival

Klinisches Erscheinungsbild und Blutgasanalyse von Polytraumapatienten für die Vorhersage von Standardgerinnungsparametern bei Ankunft in der Notaufnahme

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Abstract

Objectives

Trauma-induced coagulopathy (TIC) in multiple trauma patients is a potentially lethal complication. Whether quickly available laboratory parameters using point-of-care (POC) blood gas analysis (BGA) may serve as surrogate parameters for standard coagulation parameters is unknown. The present study evaluated TraumaRegister DGU® of the German Trauma Society for correlations between POC BGA parameters and standard coagulation parameters.

Methods

In the setting of 197 trauma centres (172 in Germany), 86,442 patients were analysed between 2005 and 2012. Of these, 40,129 (72 % men) with a mean age 46 ± 21 years underwent further analysis presenting with direct admission from the scene of the accident to a trauma centre, injury severity score (ISS)  ≥ 9, complete data available for the calculation of revised injury severity classification prognosis, and blood samples with valid haemoglobin (Hb) measurements taken immediately after emergency department (ED) admission. Correlations between standard coagulation parameters and POC BGA parameters (Hb, base excess [BE], lactate) were tested using Pearson’s test with a two-tailed significance level of p < 0.05. A subgroup analysis including patients with ISS > 16, ISS > 25, ISS > 16 and shock at ED admission, and patients with massive transfusion was likewise carried out.

Results

Correlations were found between Hb and prothrombin time (r = 0.497; p < 0.01), Hb and activated partial thromboplastin time (aPTT; r = −0.414; p < 0.01), and Hb and platelet count (PLT; r = 0.301; p < 0.01). Patients presenting with ISS ≥ 16 and shock (systolic blood pressure < 90 mmHg) at ED admission (n = 4,329) revealed the strongest correlations between Hb and prothrombin time (r = 0.570; p < 0.01), Hb and aPTT (r = −0.457; p < 0.01), and Hb and PLT (r = 0.412; p < 0.01). Significant correlations were also found between BE and prothrombin time (r = −0.365; p < 0.01), and BE and aPTT (r = 0.327, p < 0.01). No correlations were found between Hb, BE and lactate lactate.

Conclusions

POC BGA parameters Hb and BE of multiple trauma patients correlated with standard coagulation parameters in a large database analysis. These correlations were particularly strong in multiple trauma patients presenting with ISS > 16 and shock at ED admission. This may be relevant for hospitals with delayed availability of coagulation studies and those without viscoelastic POC devices. Future studies may determine whether clinical presentation/BGA-oriented coagulation therapy is an appropriate tool for improving outcomes after major trauma.

Zusammenfassung

Ziele

Die traumainduzierte Koagulopathie (trauma-induced coagulopathy, TIC) bei Polytraumapatienten ist eine potentiell letale Komplikation. Es ist nicht bekannt, ob kurzfristig verfügbare Laborparameter einer Point-of-Care-Blutgasanalyse (POC-BGA) als Surrogatparameter von Standardgerinnungsparametern dienen können. In der vorliegenden Studie wurde das TraumaRegister DGU® der deutschen Gesellschaft für Unfallchirurgie nach Korrelationen von Parametern der POC-BGA und Standardgerinnungsparametern ausgewertet.

Methoden

Im Setting von 197 Unfallkliniken (172 in Deutschland) wurden zwischen 2005 und 2012 86.442 Patienten analysiert. 40.129 (72 % männlich) Patienten mit einem Durchschnittsalter von 46 ± 21 Jahren erfüllten folgende Einschlusskriterien: Direkte Aufnahme von der Unfallstelle in eine Unfallklinik, Injury Severity Score (ISS) ≥ 9, vollständigen Datenverfügbarkeit für die Berechnung des revidierten Prognosescores für die Klassifizierung der Verletzungsschwere (RISC) und Blutproben mit validen Messungen von Hämoglobin (Hb), die direkt nach der Aufnahme in die Notaufnahme (emergency department, ED) abgenommen wurden. Korrelationen zwischen Standardgerinnungsparametern und POC-BGA-Parametern (Hb, Base Excess (BE); Laktat) wurden mit dem Pearsontest mit zweiseitigem Signifikanzniveau von p < 0,05 geprüft. Darüber hinaus wurde eine Subgruppenanalyse für Patienten mit ISS > 16, ISS > 25, ISS > 16 und Schock (systolischer Blutdruck < 90 mmHg) bei Aufnahme und für Patienten mit Massivtransfusion durchgeführt.

Ergebnisse

Korrelationen wurden zwischen Hb und Prothrombinzeit (r = 0,497; p < 0,01), Hb und aktivierter partieller Thromboplastinzeit (aPTT) (r = −0,414; p < 0,01) und zwischen Hb und Thrombozytenzahl (PLT) (r = 0,301; p < 0,01) gefunden. Patienten in den untersuchten Subgruppen zeigten dabei zunehmende Korrelation, wobei Patienten mit ISS ≥ 16 und Schock bei Aufnahme (n = 4.329) die stärksten Korrelationen zwischen Hb und Prothrombinzeit (r = 0,570; p < 0,01), Hb und aPTT (r = −0,457; p < 0,01) und zwischen Hb und PLT (r = 0,412; p < 0,01) zeigten. Eine signifikante Korrelation wurde auch zwischen BE und Prothrombinzeit (r = −0,365; p < 0,01) und zwischen BE und aPTT (r = 0,327, p < 0,01) gefunden. Zwischen Hb, BE und Laktat wurden keine Korrelationen gefunden.

Schlussfolgerungen

Die POC-BGA Parameter Hb und BE von Polytraumapatienten korrelierten mit den Standardgerinnungsparametern in der Analyse eines großen Patientenregisters. Diese Korrelationen waren vor allem bei Polytraumapatienten mit einem ISS > 16 und Schock bei Aufnahme ausgeprägt. Das könnte für Krankenhäuser mit verzögerter Verfügbarkeit von Gerinnungstests ebenso relevant sein wie für solche ohne viskoelastische POC-Verfahren. Künftige Studien müssen zeigen, ob eine nach klinischem Erscheinungsbild und/nach Blutgasanalyse orientierte Gerinnungstherapie ein geeignetes Mittel zur Verbesserung der Behandlungsergebnisse nach schwerem Trauma ist.

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Acknowledgement

The authors would like to thank all the participating hospitals of the TR-DGU. Further information is available online at www.traumaregister.de

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Authors and Affiliations

  1. Department of Anaesthesiology, Intensive Care and Emergency Medicine, Bergmannstrost Hospital, Merseburger Str. 165, 06112, Halle (Saale), Deutschland

    P. Hilbert-Carius & R. Stuttmann

  2. Department of Trauma, Reconstructive and Hand Surgery, University Hospital Jena, Jena, Deutschland

    G. O. Hofmann

  3. Institute of Research in Operative Medicine (IFOM), University Witten-Herdecke Campus Cologne-Merheim, Cologne, Deutschland

    R. Lefering

  4. Department of Anaesthesiology and Intensive Care Medicine, University Hospital Leipzig, Leipzig, Deutschland

    M. F. Struck

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  1. P. Hilbert-Carius
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German TraumaRegister DGU®

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Correspondence to P. Hilbert-Carius.

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Conflicts of interest

P. Hilbert-Carius has received honoraria from CSL Behring. G. O. Hofmann, R. Lefering, R. Stuttmann and M. F. Struck declare that they have no conflicts of interest.

The accompanying manuscript does not include studies on humans or animals.

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Hilbert-Carius, P., Hofmann, G.O., Lefering, R. et al. Clinical presentation and blood gas analysis of multiple trauma patients for prediction of standard coagulation parameters at emergency department arrival. Anaesthesist 65, 274–280 (2016). https://doi.org/10.1007/s00101-016-0150-y

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  • DOI: https://doi.org/10.1007/s00101-016-0150-y

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