Hemostasis during the early stages of trauma: comparison with disseminated intravascular coagulation

Abstract

Introduction: We tested two hypotheses that disseminated intravascular coagulation (DIC) and acute coagulopathy of trauma-shock (ACOTS) in the early phase of trauma are similar disease entities and that the DIC score on admission can be used to predict the prognosis of patients with coagulopathy of trauma.

Methods: We conducted a retrospective study of 562 trauma patients, including 338 patients whose data were obtained immediately after admission to the emergency department. We collected serial data for the platelet counts, global markers of coagulation and fibrinolysis, and antithrombin levels. DIC was diagnosed according to the Japanese Association for Acute Medicine (JAAM) DIC scoring system, and ACOTS was defined as a prothrombin-time ratio of >1.2.

Results: The higher levels of fibrin/fibrinogen degradation products (FDP) and D-dimer and greater FDP/D-dimer ratios in the DIC patients suggested DIC with the fibrinolytic phenotype. The DIC patients with the fibrinolytic phenotype exhibited persistently lower platelet counts and fibrinogen levels, increased prothrombin time ratios, higher FDP and D-dimer levels, and lower antithrombin levels compared with the non-DIC patients on arrival to the emergency department and during the early stage of trauma. Almost all ACOTS patients met the criteria for a diagnosis of DIC; therefore, the same changes were observed in the platelet counts, global markers of coagulation and fibrinolysis, and antithrombin levels as noted in the DIC patients. The JAAM DIC score obtained immediately after arrival to the emergency department was an independent predictor of massive transfusion and death due to trauma and correlated with the amount of blood transfused.

Conclusions: Patients who develop DIC with the fibrinolytic phenotype during the early stage of trauma exhibit consumption coagulopathy associated with increased fibrin(ogen)olysis and lower levels of antithrombin. The same is true in patients with ACOTS. The JAAM DIC score can be used to predict the prognosis of patients with coagulopathy of trauma.

Figure 1

Relations between DIC (bold circle, n = 201) and ACOTS (open circle, n = 123). Almost all ACOTS patients (n = 104) were included as DIC patients. Only 19 patients with ACOTS did not meet the DIC criteria.

Figure 2

The bar graphs show the changes in the platelet counts, prothrombin time ratio (PT ratio), and levels of fibrinogen, FDP, D-dimer, and antithrombin in the total 562 patients. ACOTS, patients who met the ACOTS diagnostic criteria; control, patients who did not meet the JAAM DIC criteria; ISTH, patients who simultaneously met both the JAAM and ISTH DIC criteria; JAAM, patients who met the JAAM DIC criteria. The ACOTS patients overlapped with control, JAAM, and ISTH patients. *P < 0.05; **P < 0.01; †P < 0.001 versus control.

Figure 3

The bar graphs show the changes in the platelet counts, prothrombin-time ratio (PT ratio), and levels of fibrinogen, FDP, D-dimer, and antithrombin in the 338 patients for whom data were collected immediately after admission in the emergency department. ACOTS, patients who met the ACOTS diagnostic criteria; control, patients who did not meet the JAAM DIC criteria; ISTH, patients who simultaneously met both the JAAM and ISTH DIC criteria; JAAM, patients who met the JAAM DIC criteria. The ACOTS patients overlapped with the control, JAAM, and ISTH patients. For time points 0 to 3, refer to the Methods section in detail. *P < 0.05; **P < 0.01; †P < 0.001 versus control.