Initial experiences with point-of-care rapid thrombelastography for management of life-threatening postinjury coagulopathy.

BACKGROUND: Massive transfusion (MTP) protocol design is hindered by lack of accurate assessment of coagulation. Rapid thrombelastography (r-TEG) provides point-of-care (POC) analysis of clot formation. We designed a prospective study to test the hypothesis that integrating TEG into our MTP would facilitate goal-directed therapy and provide equivalent outcomes compared to conventional coagulation testing. STUDY DESIGN AND METHODS: Thiry-four patients who received more than 6 units of red blood cells (RBCs)/6 hours who were admitted to our Level 1 trauma center after r-TEG implementation (TEG) were compared to 34 patients admitted prior to TEG implementation (Pre-TEG). Data are presented as mean±SEM. RESULTS: Emergency department pre-TEG versus TEG shock, and coagulation indices, were not different: systolic blood pressure (94 mmHg vs. 101 mmHg), temperature (35.3°C vs. 35.9°C), pH (7.16 vs. 7.11), base deficit (-13.0 vs. -14.7), lactate (6.5 vs. 8.1), international normalized ratio (INR; 1.59 vs. 1.83), and partial thromboplastin time (48.3 vs. 57.9). Although not significant, patients with Injury Severity Score range 26 to 35 were more frequent in the pre-TEG group. Fresh-frozen plasma (FFP):RBCs, platelets:RBCs, and cryoprecipitate (cryo):RBC ratios were not significantly different at 6 or 12 hours. INR at 6 hours did not discriminate between survivors and nonsurvivors (p=0.10), whereas r-TEG "G" value was significantly associated with survival (p=0.03), as was the maximum rate of thrombin generation (MRTG; mm/min) and total thrombin generation (TG; area under the curve) (p=0.03 for both). Patients with MRTG of more than 9.2 received significantly less components of RBCs, FFP, and cryo (p=0.048, p=0.03, and p=0.04, respectively). CONCLUSION: Goal-directed resuscitation via r-TEG appears useful for management of trauma-induced coagulopathy. Further experience with POC monitoring could result in more efficient management leading to a reduction of transfusion requirements.

Refractory postinjury thrombocytopenia is associated with multiple organ failure and adverse outcomes.

BACKGROUND: Postinjury multiple organ failure (MOF) remains the leading cause of morbidity and late mortality after severe trauma. Our previous work consistently identified an association between thrombocytopenia and progression to MOF. In addition, recent studies suggest that platelets play a critical role in postinjury hyperinflammation. Therefore, we hypothesized that postinjury thrombocytopenia is a marker for progression to MOF. METHODS: One thousand four hundred fifteen critically injured surgical intensive care unit patients surviving>48 hours were prospectively collected over 12 years. Variables studied included age, Injury Severity Score (ISS), red blood cell (RBC)/12 h, MOF (Denver MOF score), death, infectious complications, and noninfectious complications. Thrombocytopenia was defined as platelets<80k. Logistic regression was applied to identify independent predictors of MOF and death. RESULTS: Mean±standard error of the mean ISS, age, and RBC were 29.3±11.3; 37.4 years±16.6 years; and 4.4 units±5 units. MOF developed in 346 patients (24%) and 118 patients (8%) died. Thrombocytopenia occurred in 35% of patients within 48-hour postinjury and was associated with a significant increase in ISS, RBC transfused, and age. Logistic regression confirmed that thrombocytopenia was a major independent risk factor for all adverse outcomes with an odds ratio of 2.4 for developing MOF and 3.4 for death. After adjustment for these factors, a relative increase in platelet count from day 3 to day 10 was associated with a significantly lower likelihood of MOF and death. CONCLUSION: Early postinjury thrombocytopenia is an independent risk factor for MOF, death, and other complications. Following platelet count dynamics over the first several days postinjury can help predict which high-risk patient will develop these adverse outcomes.

Fatal gunshot wounds to the head: a critical appraisal of organ donation rates.

BACKGROUND: Patients sustaining fatal gunshot wounds to the head are often young, without associated comorbidities, and are potentially ideal transplantation candidates. METHODS: A 5-year review of a level I trauma center's prospective database was performed for all patients sustaining fatal gunshot wounds to the head. Demographic, physiologic, anatomic, and laboratory variables were collected. RESULTS: Sixty-eight patients were identified, of whom 10 (14.7%) were organ donors. Of 25 admitted to the intensive care unit who eventually did not become donors, 15 (60%) were due to lack of consent. CONCLUSIONS: Despite frequent intensive care unit admissions, organ donation is infrequent following fatal gunshot wounds to the head, primarily because of lack of consent. Improved communication with next of kin could improve organ recovery and reduce futile care in this group.