Fibrin Clot Formation Dynamics in Trauma Patients
CCCF ePoster library. Gomez Builes J. Nov 2, 2016; 150986; 105
Dr. Johana C Gomez Builes
Dr. Johana C Gomez Builes
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Topic: Retrospective or Prospective Cohort Study

Fibrin Clot Formation Dynamics in Trauma Patients


Gomez Builes, Johana Carolina1,2;  Sholzberg, Michelle3; McFarlan, Amanda4; de Oliveira M, Leonardo5; Rizoli, Sandro1,4.
1Critical Care Department, St Michael's Hospital, Toronto, Canada. 2Institute of Medical Studies, University of Toronto, Toronto, Canada. Medical Director Coagulation Laboratory, St Michael's Hospital, Toronto, Canada. 4 Trauma and Acute Care Surgery, St Michael's Hospital, Toronto, Canada. 5Neuroscience Research Program, Keenan Research Center of the Li KaShing Knowledge Institute of St. Michael’s Hospital, Toronto, Canada.



Abstract:

INTRODUCTION:
The development of acute traumatic coagulopathy is associated with increased mortality. Thrombin generation (TG) is pivotal for an effective hemostatic response. Tests for assessing TG are laborious, costly, and unsuitable for emergency settings. Alternatively, thromboelastometry (TEM), a point of care test, assess the clot formation dynamics and its strength. Also, provides a profile of the speed of clot growth from initiation to reach the maximum velocity. Recent studies have shown a strong correlation between TEM fibrin clot waveform analysis and TG curves, suggesting that TEM may indirectly measure TG kinetics.
OBJECTIVES:
To describe the velocity profile of clot formation (TG) assessed by TEM in adult trauma patients and explore whether they are associated with the severity of the trauma and clinical outcomes such as blood transfusion (a surrogate for shock) and mortality.
METHODS:
Retrospective analysis of 794 patients admitted to a Level I Trauma Center. Groups were classified as severe trauma (ISS >24), moderate (ISS 16-24), or mild (ISS 4-15). Patients with ISS <4 formed the control group. Routine coagulation tests and TEM (ROTEM®: EXTEM and FIBTEM) at trauma bay were analyzed, as well as the mortality and blood transfusion in the first 24 hours. Mann-Whitney U-test was used for comparison between groups.
RESULTS:
Severe trauma (n=120), moderate trauma (n=148), mild trauma (n=312), and control group (n=214) were included in the study. Mean Age was 46.8 years (±16.1 SD). Compared to control group, two patterns were evident. One pattern had a longer time to reach the greatest clot growth speed (MaxV-t), a lower speed of maximal clot formation (MaxV) resulting in decreased clot strength (MCF). Severe trauma patients (maxV-t 125 vs. 119s, p=0.002 and MaxV 14 vs. 16 mm/min, p= 0.0001, MCF 62 vs. 63, p=0.01) and patients requiring blood transfusion (MaxV-t 124 vs. 119s, p=0.018 and MaxV 13 vs. 16 mm/min, p= < 0.0001, MCF 62 vs. 63mm, p=< 0.0001) fit in this profile. The other pattern had both longer time to MaxV, and reduced MaxV but no difference in clot strength compared to controls. This profile was present among non-survivors (maxV 14 vs. 16 mm/min, p= 0.015, MaxV-t 133 vs. 119s, p=0.0001, MCF 62 vs. 63 mm, p=0.2).
CONCLUSION:
Our study is one of the first to characterize the early (hospital admission) changes in fibrin clot kinetics as an indirect measure of thrombin generation in trauma patients and the possible clinical implications; It adds to the current (and very scarce) knowledge on the early trauma-induced changes in coagulation; The most significant findings of this study are that TG is significantly affected by the severity of the injuries (ISS), and different in patients in shock (need for blood transfusion) and non-survivors but not necessarily more severely deranged. While patients receiving blood transfusions had a lower speed of maximum clot formation, a delayed time to reach the maximal velocity of clot growth, and reduced clot strength, non-survivors had the same clot strength as controls. Our findings underscore the importance of the dynamics parameters of thrombin generation and clot formation in trauma patients, as a way to assess the hemostatic potential and develope effective and timely hemostatic strategies.


References:

1. Matijevic, N. et al., 2014. Cellular microparticle and thrombogram phenotypes in the Prospective Observational Multicenter Major Trauma Transfusion (PROMMTT) Study: Correlation with coagulopathy. Thrombosis Research, 134(3), pp.652–658.
2. Cardenas, J.C. et al., 2014. Measuring thrombin generation as a tool for predicting hemostatic potential and transfusion requirements following trauma. Journal of Trauma and Acute Care Surgery, 77(6), pp.839–845.



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