Impact of initial coagulation and fibrinolytic markers on mortality in patients with severe blunt trauma: a multicentre retrospective observational study

Plasma D-Dimer Levels Can Provide Useful Diagnostic Information on Acute Vertebral Compression Fractures in Patients with Low Back Pain in the Emergency Room

BACKGROUND

Patients with acute vertebral compression fractures (aVCFs) are frequently transferred to an emergency department by ambulance. The most useful imaging modality is magnetic resonance imaging (MRI); however, which patients should be prioritized for MRI evaluation may be unclear. The aim of this study was to evaluate plasma D-dimer levels as a biomarker for aVCFs.

METHODS

This retrospective cohort study included patients with low back pain in the emergency department between November 2017 and October 2020. Patients with infections, patients with coagulation disorders, and patients without D-dimer level measurements were excluded. The presence of an aVCF was detected with MRI. Blood samples were collected for routine blood tests. The predictive factors for aVCFs were evaluated with univariate and multivariable logistic regression analyses.

RESULTS

Overall, 191 consecutive MRI evaluations were ordered. After exclusions, 101 patients were reviewed. Based on MRI, 65 (64.4%) patients were diagnosed with aVCF. The presence of aVCF was significantly correlated with age (odds ratio [OR] = 1.052, 95% confidence interval [CI] 1.018-1.191), an old vertebral compression fracture (OR = 3.290, 95% CI 1.342-8.075), hemoglobin (OR = 0.699, 95% CI 0.535-0.912), and D-dimer levels (OR = 1.829, 95% CI 1.260-2.656). Results from a multivariable logistic regression analysis showed that D-dimer levels (OR = 1.642, 95% CI 1.188-2.228) remained a significant risk factor for the presence of aVCFs after adjustment for potential confounders.

CONCLUSIONS

Plasma D-dimer levels can provide useful diagnostic information about whether an aVCF is present.

Early prediction for massive fresh frozen plasma transfusion based on fibrinogen/fibrin degradation products and D-dimer in patients with blunt trauma: a single-center, retrospective cohort study

PURPOSE

This study aimed to examine the association of fibrinogen/fibrin degradation product (FDP) values in comparison with D-dimer and fibrinogen (Fib) values and the need for massive fresh frozen plasma (FFP) transfusion in patients with blunt trauma.

METHODS

This retrospective study included patients with blunt trauma aged ≥ 18 years who were transported directly to the tertiary care hospital between April, 2012, and March, 2021. Massive FFP transfusion was defined as a composite outcome of at least 10 units of FFP or death for any cause except for cerebral herniation, within 24 h after hospital arrival. We evaluated the diagnostic accuracy of predicting the need for massive FFP transfusions using FDP, D-dimer, and Fib levels at the time of hospital arrival.

RESULTS

A total of 2160 patients were eligible for the analysis, of which 167 fulfilled the criteria for the composite outcome. The area under the curve and 95% confidence interval for FDP, D-dimer, and Fib levels were 0.886 (0.865-0.906), 0.885 (0.865-0.906), and 0.771 (0.731-0.810), respectively. When the cutoff values of FDP and D-dimer were set at 90 μg/mL and 45 μg/mL, the sensitivity values were 77% and 78%, the positive predictive values were 28% and 27%, and the negative predictive values were both 98%, respectively. In contrast, the sensitivity of Fib was low regardless of the cutoff value.

CONCLUSION

FDP and D-dimer levels at the time of hospital arrival showed a higher predictive accuracy for the need for massive FFP transfusion than Fib.

The European guideline on management of major bleeding and coagulopathy following trauma: sixth edition

BACKGROUND

Severe trauma represents a major global public health burden and the management of post-traumatic bleeding continues to challenge healthcare systems around the world. Post-traumatic bleeding and associated traumatic coagulopathy remain leading causes of potentially preventable multiorgan failure and death if not diagnosed and managed in an appropriate and timely manner. This sixth edition of the European guideline on the management of major bleeding and coagulopathy following traumatic injury aims to advise clinicians who care for the bleeding trauma patient during the initial diagnostic and therapeutic phases of patient management.

METHODS

The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma included representatives from six European professional societies and convened to assess and update the previous version of this guideline using a structured, evidence-based consensus approach. Structured literature searches covered the period since the last edition of the guideline, but considered evidence cited previously. The format of this edition has been adjusted to reflect the trend towards concise guideline documents that cite only the highest-quality studies and most relevant literature rather than attempting to provide a comprehensive literature review to accompany each recommendation.

RESULTS

This guideline comprises 39 clinical practice recommendations that follow an approximate temporal path for management of the bleeding trauma patient, with recommendations grouped behind key decision points. While approximately one-third of patients who have experienced severe trauma arrive in hospital in a coagulopathic state, a systematic diagnostic and therapeutic approach has been shown to reduce the number of preventable deaths attributable to traumatic injury.

CONCLUSION

A multidisciplinary approach and adherence to evidence-based guidelines are pillars of best practice in the management of severely injured trauma patients. Further improvement in outcomes will be achieved by optimising and standardising trauma care in line with the available evidence across Europe and beyond.

Longitudinal D-Dimer Trajectories and the Risk of Mortality in Abdominal Trauma Patients: A Group-Based Trajectory Modeling Analysis

This study aimed to identify the long-term D-dimer trajectory patterns and their associations with in-hospital all-cause mortality in abdominal trauma patients. This is a retrospective cohort study of general adult abdominal trauma patients admitted to Jinling Hospital (Nanjing, China) between January 2010 and April 2020. Group-based trajectory modeling was applied to model D-dimer trajectories over the first 50 days post-trauma. A multivariable logistic regression was performed to estimate the associations between D-dimer trajectories and in-hospital all-cause mortality. A total of 309 patients were included. We identified four distinct D-dimer trajectories: group 1 (57.61%; "stable low"), group 2 (28.16%; "moderate-decline"), group 3 (8.41%; "high-rapid decline"), and group 4 (5.83%; "high-gradual decline"). The SOFA score (p = 0.005) and ISS (p = 0.001) were statistically higher in groups 3 and 4 than in groups 1 and 2. The LMWH and UFH did not differ between groups 3 and 4. Compared with the patients in group 1, only the patients in group 4 were at a higher risk of in-hospital all-cause mortality (OR = 6.94, 95% CI: 1.20-40.25). The long-term D-dimer trajectories post-trauma were heterogeneous and associated with mortality. An initially high and slowly-resolved D-dimer might function as the marker of disease deterioration, and specific interventions are needed.

Does Antithrombotic Therapy Affect Outcomes in Major Trauma Patients? A Retrospective Cohort Study from a Tertiary Trauma Centre

Antithrombotic therapy may affect outcomes in major trauma but its role is not fully understood. We aimed to investigate adverse outcomes among those with and without antithrombotic treatment in major trauma. Material and methods: This is a retrospective study conducted at the Emergency Department (ED) of the University Hospital of Genoa, a tertiary trauma center, including all major trauma between January 2019 and December 2020. Adverse outcomes were reviewed among those without antithrombotic treatment (Group 0), on antiplatelet treatment (Group 1), and on anticoagulant treatment (Group 2). Results: We reviewed 349 electronic charts for full analysis. Group 0 were n = 310 (88.8%), Group 1 were n = 26 (7.4%), and Group 2 were n = 13 (3.7%). In-hospital death and ICU admission, respectively, were: n = 16 (5.6%) and n = 81 (26%) in Group 0, none and n = 6 (25%) in Group 1, and n = 2 (15.8%) and n = 4 (30.8%) in Group 2 (p = 0.123-p = 0.874). Altered INR (OR 5.2) and increasing D-dimer levels (AUC: 0.81) correlated to increased mortality. Discussion: Group 2 showed higher mortality than Group 0 and Group 1, however Group 2 had fewer active treatments. Of clotting factors, only altered INR and elevated D-dimer levels were significantly correlated to adverse outcomes. Conclusions: Anticoagulant but not antiplatelet treatment seems to produce the worst outcomes in major trauma.

The Association Between D-dimer Levels and Long-Term Neurological Outcomes of Patients with Traumatic Brain Injury: An Analysis of a Nationwide Observational Neurotrauma Database in Japan

BACKGROUND

We evaluated the association between D-dimer (DD) levels and long-term neurological prognoses among patients with isolated traumatic brain injury.

METHODS

Using data from multiple centers in the Japanese Neurotrauma Data Bank, we conducted an observational retrospective cohort study. Patients with isolated traumatic brain injury (head Abbreviated Injury Scale score > 2; any other Abbreviated Injury Scale score < 3) who were registered in the Japanese Neurotrauma Data Bank from 2015 to 2017 were recruited. We excluded patients younger than age 16 years and those who developed cardiac arrest at hospital admission. We also excluded patients with unknown Glasgow Outcome Scale (GOS) scores at 6 months after injury and those with unknown DD levels. The primary outcome was the association of DD levels with GOS scores at 6 months. We defined GOS scores 1 to 3 as poor and GOS scores 4 and 5 as good. The secondary outcome was the association of DD levels with mortality at 6 months after injury. We conducted multivariate logistic regression analyses to calculate the adjusted odds ratios of DD levels at hospital admission and GOS scores at 6 months as tertiles with 95% confidence intervals (CIs). A total of 293 patients were enrolled (median age 67 years; interquartile range 51-79 years). The median DD level was 27.1 mg/L (interquartile range 9.7-70.8 mg/L), and 58.0% (n = 170) had poor GOS scores at 6 months.

RESULTS

The multivariable logistic regression analysis indicated that the adjusted odds ratios were 2.52 (95% CI 1.10-5.77) for middle DD levels with poor GOS scores at 6 months and 5.81 (95% CI 2.37-14.2) for high DD levels with poor GOS scores at 6 months.

CONCLUSIONS

We revealed an association between DD levels and poor long-term neurological outcomes among patients with isolated traumatic brain injury.

High levels of plasma fibrinogen and prothrombin time are related to post-stroke emotional impairment

INTRODUCTION

Studies have shown that high levels of the fibrinogen (FIB) are related to anxiety and depression. However, the relationship between FIB and post-stroke emotional impairment (PSEI) remains unclear, which includes post-stroke anxiety (PSA) and post-stroke depression (PSD).

METHODS

A total of 555 patients with acute ischemic stroke (AIS) were enrolled in this study. Ultimately, 443 patients completed 1-month follow-up. Blood samples were collected at hospital admission. Clinical depression and anxiety were evaluated 1 month after stroke.

RESULTS

High levels of FIB were observed in patients with PSEI compared with the non-EI group (p = 0.003). Levels of FIB were divided into three tertiles, and the prevalence of PSEI was significantly higher in the third FIB tertile (p = 0.016). After adjusting potential confounders, the third FIB tertile was independently associated with the prevalence of PSEI (OR = 1.785, 95%CI = 1.049-3.039, p = 0.033), taking the first tertile as a reference. In this model, prothrombin time (PT) was also independently associated with the prevalence of PSEI (OR = 1.602, 95%CI = 1.181-2.173, p = 0.002).

CONCLUSION

High levels of plasma FIB and PT are associated with the prevalence of PSEI.

The fibrin/fibrinogen degradation product level on arrival in trauma patients is a better predictor of a fatal outcome than physiological or anatomical severity: A retrospective chart review

Aim

We performed a retrospective investigation to determine the factors, including vital signs, severity of traumatic anatomical abnormality and biochemical data, which are most useful for predicting the outcomes of trauma patients after admission.

Methods

A retrospective medical chart review was performed for all trauma patients who were admitted to our department from September 2017 to August 2019. These subjects were then divided into two groups according to whether they survived to hospital discharge or not.

Results

During the investigation period, 790 patients were enrolled as subjects (Death group, n = 34; survival group, n = 756). The injury severity score, serum glucose level, prothrombin time, international normalized ratio and fibrin/fibrinogen degradation product level in the Death group were significantly greater than those in the Survival group. A multivariate analysis showed that the fibrin/fibrinogen degradation product level was a significant predictor of a fatal outcome (odds ratio 1.00, 95% confidence interval 1.0008-1.0040, p value = 0.0008).

Conclusions

The fibrin/fibrinogen degradation product levels on arrival may be a better predictor of a fatal outcome in trauma patients than physiological or anatomical severity.

Efficacy and safety of tranexamic acid administration in traumatic brain injury patients: a systematic review and meta-analysis

Background

The exacerbation of intracranial bleeding is critical in traumatic brain injury (TBI) patients. Tranexamic acid (TXA) has been used to improve outcomes in TBI patient. However, the effectiveness of TXA treatment remains unclear. This study aimed to assess the effect of administration of TXA on clinical outcomes in patients with TBI by systematically reviewing the literature and synthesizing evidence of randomized controlled trials (RCTs).

Methods

MEDLINE, the Cochrane Central Register of Controlled Trials, and Igaku Chuo Zasshi (ICHUSHI) Web were searched. Selection criteria included randomized controlled trials with clinical outcomes of adult TBI patients administered TXA or placebo within 24 h after admission. Two investigators independently screened citations and conducted data extraction. The primary “critical” outcome was all-cause mortality. The secondary “important” outcomes were good neurological outcome rates, enlargement of bleeding, incidence of ischemia, and hemorrhagic intracranial complications. Random effect estimators with weights calculated by the inverse variance method were used to report risk ratios (RRs).

Results

A total of 640 records were screened. Seven studies were included for quantitative analysis. Of 10,044 patients from seven of the included studies, 5076 were randomly assigned to the TXA treatment group, and 4968 were assigned to placebo. In the TXA treatment group, 914 patients (18.0%) died, while 961 patients (19.3%) died in the placebo group. There was no significant difference between groups (RR, 0.93; 95% confidence interval, 0.86–1.01). No significant differences between the groups in other important outcomes were also observed.

Conclusions

TXA treatment demonstrated a tendency to reduce head trauma-related deaths in the TBI population, with no significant incidence of thromboembolic events. TXA treatment may therefore be suggested in the initial TBI care.

Point-of-Care diagnostics of coagulation in the management of bleeding and transfusion in trauma patients

PURPOSE OF REVIEW

Trauma-associated bleeding and coagulopathy require timely identification, prevention, and effective treatment. The present review summarizes the recent literature around point-of-care (POC) coagulation tests, their usefulness in the management of trauma-induced coagulopathy (TIC), their impact on trauma patient outcomes, and the requirement of quality assurance.

RECENT FINDINGS

Best practice algorithms to manage TIC have been compiled in the 2019 European Guideline on the management of major bleeding and coagulopathy after trauma. Evidence supports the use of goal-directed approaches to manage TIC. POC coagulation tests can accelerate and tailor individualized therapies. Recent findings emphasize: the time sparing of POC tests in prehospital settings and the validity of POC measurements in extreme environments; the potential scalability of POC-guided TIC algorithms in burn injuries and the pediatric population; the need for careful considerations of strategies to monitor and reverse the effects of direct oral anticoagulants in major trauma.

SUMMARY

In contrast to an abundance of reviews and practical approaches to POC coagulation management in trauma patients, there is a scarcity of research in the field and large-scale clinical trials are urgently needed. The paneuropean multicenter trial Implementing Treatment Algorithms for the Correction of Trauma Induced Coagulopathy (iTACTIC) will inform on the potential of viscoelastic tests to augment transfusion protocols for better patient outcomes.