Value of hypocalcaemia for predicting trauma-induced coagulopathy in elderly trauma patients / 中华急诊医学杂志

Objective:To investigate the value of hypocalcaemia for predicting trauma-induced coagulopathy (TIC) in elderly trauma patients.Methods:The clinical data of elderly trauma patients in emergency ICU of the Second Affiliated Hospital of Zhejiang University School of Medicine from January 2015 to September 2020 were retrospectively analyzed, including age, sex, site of injury, injury severity score (ISS), Glasgow coma scale (GCS), admission arterial blood gas analysis (Ca 2+, K +), venous blood biochemical electrolyte (Ca 2+, K +, Na +); international normalized ratio (INR), activated partial thromboplastin time (APTT), prothrombin time (PT), fibrinogen (FIB), use of blood products, length of stay, length of stay in ICU, total cost, and clinical prognosis. Receiver operating characteristic (ROC) curves and multivariate logistic regression analysis were performed to estimate the contribution of hypocalcaemia to triggering TIC in elderly trauma patients. Results:Totally 371 elderly trauma patients were included with a mean age of (72.5±6.8) years, and 248 (66.8%) were male. ISS score of the TIC group was higher than that of the non-TIC group [25(20, 34) vs. 21(16, 29)]. Compared with the non-TIC group, the incidence of chest injury, abdominal injury and limb injury were significantly higher , while the incidence of head and neck injury were significantly lower in the TIC group (all P<0.05). The biochemical blood calcium in the TIC group was significantly lower than that in the non-TIC group [(1.97±0.19) mmol/L vs. (2.15±0.16) mmol/L, P<0.001], but there was no significant difference in blood gas calcium between the two groups. The APTT value of the TIC group [(47.6±21.8) s vs. (33.8±4.1) s], PT value [(18.0±3.9) s vs. (13.7±0.8) s] were significantly higher than that of the non-TIC group, and FIB level was significantly lower than that of the non-TIC group[(1.7±0.8) g/L vs. (2.8±0.9) g/L] (all P<0.01). The utilization rate of blood products and the total cost in the TIC group were higher than that in the non-TIC group, while the recovery rate in the TIC group was lower than that in the non-TIC group (69.8% vs. 86.4%, P<0.001). Multivariate logistic regression analysis showed that hypocalcaemia was an independent risk factor for TIC in elderly trauma patients ( OR=5.830, 95% CI: 3.295-10.314). The area under ROC curve of correlation between biochemical calcium and TIC was 0.779 (95% CI: 0.728-0.831). The optimal diagnostic cut-off value was 2.06 mmol/L. Conclusions:The decrease of biochemical serum calcium level is an independent risk factor for TIC in elderly trauma patients. Positive correction of TIC in elderly trauma patients contributes to continuous improvement of clinical prognosis.

What's new in trauma 2020 / 中华创伤杂志(英文版)

Throughout the past 2020, the pandemic COVID-19 has caused a big global shock, meanwhile it brought a great impact on the public health network. Trauma emergency system faced a giant challenge and how to manage trauma under the pandemic of COVID-19 was widely discussed. However, the trauma treatment of special population (geriatric patients and patients taking anticoagulant drugs) has received inadequate attention. Due to the high mortality following severe traumatic hemorrhage, hemostasis and trauma-induced coagulopathy are the important concerns in trauma treatment. Sepsis is another topic should not be ignored when we talking about trauma. COVID-19 itself is a special kind of sepsis, and it may even be called as serious systemic infection syndrome. Sepsis has been become a serious problem waiting to be solved urgently no matter in the fields of trauma, or in intensive care and infection, etc. This article reviewed the research progress in areas including trauma emergency care, trauma bleeding and coagulation, geriatric trauma and basic research of trauma within 2020.

The effect of serum HMGB1 levels on the severity and prognosis of critical ill patients with early trauma-induced coagulopathy in the intensive care unit / 解放军医学杂志

Objective: To analyze the influence of serum high mobility group box-1 protein (HMGB1) levels on the severity and prognosis of critical ill patients at the early of trauma-induced coagulopathy (TIC) in intensive care unit (ICU). Methods: 43 cases of critical ill patients with severe trauma were included during January 1, 2017 to December 31, 2018 in ICU of Foshan Hospital of Traditional Chinese Medicine. International normalized ratio (INR) >1.2 was applied as the diagnosis criterion of TIC. The patients was divided into TIC group (n=23) and control group (n=20). Their age, sex, injury mechanism, the interval between injury and admission to ICU (delay time), the interval between injury and coagulopathy correction (correction time), ISS scores, APACHE II scores at admission to ICU were recorded, and the activated partial thromboplastin time (APTT), prothrombin time (PT), INR, fibrinogen (Fib), platelet counts (PLT), C-reactive protein (CRP) and procalcitonin (PCT) levels were detected meanwhile. The serum HMGB1 levels were examined through ELISA. The blood transfusion volume (red blood cells, RBC and fresh frozen plasma, FFP), ventilation time, ICU stay and 28-day mortality rate were statistically analyzed. Results: TIC occurred in 53.5% of critical ill trauma patients in ICU. There were no significant differences in the age, sex, injury mechanism, delay time, APACHE II scores, ISS scores, APTT, PT, CRP and PCT levels between two groups (P>0.05). Compared with control group, the Fib and PLT levels were significantly reduced in the TIC group, and the ventilation time, blood transfusion volume of RBC and FFP, infection rate and organ dysfunction rate were remarkably increased (P<0.05). Besides, the 28-day mortality rate revealed a raised tendency in TIC group (P=0.091). Simultaneously, the serum HMGB1 levels at admission to ICU were significantly increased in the TIC group, and the serum HMGB1 level in the death subgroup was much higher than that in the survivors, as same as those in the TIC subgroup analysis (P=0.000). The correlation analysis disclosed that serum HMGB1 levels at admission was positively related to delay time, correction time, APACHE II score, ISS score, ventilation time, INR levels, APTT, CRP and PCT levels at admission (r=0.648, 0754, 0.526, 0.516, 0.521, 0.509, 0.432, 0.592, 0.375), and was negatively associated with Fib levels, PLT value, infection incidence rate, organ dysfunction rate and 28-day mortality rate (r=-0.424, -0.571, -0.505, -0.396, -0.765). There were significant differences in the delay time, correction time, ISS scores, transfusion volume, serum HMGB1 levels, PLT value, APTT and CRP levels between death subgroup and survivor subgroup of TIC patients (P<0.05), and serum HMGB1 levels and PLT value at admission were independent risk factors in the multivariable logistic regression analysis (P=0.004, 0.011). For the TIC sub-group trauma patients, the AUC of serum HMGB1 levels was 0.897(95%CI 0.748-1.000, P=0.002), the best cutoff value was 54.60 ng/ml with Youden index of 0.808. Conclusions: The PLT levels and serum HMGB1 levels at admission to ICU are independent risk factors of critical ill patients with severe trauma. The serum HMGB1 levels is closely related to severity and prognosis, and can predict the 28-day mortality rate of critical ill patients with TIC.

Study on the diagnosis and transfusion treatment of thrombelastography for trauma-induced coagulopathy / 中华急诊医学杂志

Objective@#To assess the diagnosis of thrombelastography (TEG) for trauma-induced coagulopathy (TIC) and explore whether TEG could guide transfusion for TIC patients.@*Methods@#We retrospectively analyzed all trauma patients who underwent the TEG and conventional coagulation tests (CCTs) admission in the emergency intensive care unit from February to December 2018. The definition of TIC is prothrombin time (PT) 18 s, international normalized ratio (INR) 1.5, activated partial thromboplastin time (APTT) 60 s or platelet count (PLT) 100×109/L. The diagnostic value of TEG for TIC was evaluated by receiver operating characteristic curve, area under the curve (AUC), sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV), and the transfusion guidance of TEG for TIC patients was assessed by multivariate regression analyses.@*Results@#A total of 242 patients were included, including 62 patients in the TIC group and 180 patients in the non-TIC group. The differences in TEG between the two groups were statistically significant. The AUCs of TIC assessed by maximum amplitude (MA) and coagulation index (CI) were the largest, 0.779 and 0.786 respectively, and the sensitivity were greater than 80% and NPV were greater than 90%. The sensitivity, PPV and NPV of reaction time (R) were minimal. After confounders were controlled, all TEG values were correlated with blood volumes within the first 24 h and massive transfusion, of which R had the highest odds ratio and regression coefficient.@*Conclusions@#MA and CI have the highest diagnostic value, while R has little diagnostic value but a relatively large blood therapeutic significance of TIC. MA < 52.9 mm or CI < -1.0 can be used as a threshold for identifying TIC. The diagnosis of TIC and the guidance transfusion for TIC patients by TEG is beneficial.

Lethal triad of trauma / 中国小儿急救医学

Patients with severe trauma usually present with lethal triad of trauma,which is composed of hypothermia,acidosis and trauma induced coagulopathy,and is closely related to poor prognosis of patients with trauma. Great efforts should be still made to evaluate the pathophysiological changes of patients with severe trauma,upgrade clinicians′ understanding of lethal triad of trauma,early identification and interven-tion,implement effective management such as injury controlled resuscitation,and further improve the progno-sis of patients.

Study on the diagnosis and transfusion treatment of thrombelastography for trauma-induced coagulopathy / 中华急诊医学杂志

Objective To assess the diagnosis of thrombelastography (TEG) for trauma-induced coagulopathy (TIC) and explore whether TEG could guide transfusion for TIC patients.Methods We retrospectively analyzed all trauma patients who underwent the TEG and conventional coagulation tests (CCTs) admission in the emergency intensive care unit from February to December 2018.The definition of TIC is prothrombin time (PT) 18 s,international normalized ratio (INR) 1.5,activated partial thromboplastin time (APTT) 60 s or platelet count (PLT) 100 x 109/L.The diagnostic value of TEG for TIC was evaluated by receiver operating characteristic curve,area under the curve (AUC),sensitivity,specificity,positive predictive value (PPV) and negative predictive value (NPV),and the transfusion guidance of TEG for TIC patients was assessed by multivariate regression analyses.Results A total of 242 patients were included,including 62 patients in the TIC group and 180 patients in the non-TIC group.The differences in TEG between the two groups were statistically significant.The AUCs of TIC assessed by maximum amplitude (MA) and coagulation index (CI) were the largest,0.779 and 0.786 respectively,and the sensitivity were greater than 80％ and NPV were greater than 90％.The sensitivity,PPV and NPV of reaction time (R) were minimal.After confounders were controlled,all TEG values were correlated with blood volumes within the first 24 h and massive transfusion,of which R had the highest odds ratio and regression coefficient.Conclusions MA and CI have the highest diagnostic value,while R has little diagnostic value but a relatively large blood therapeutic significance of TIC.MA ＜ 52.9 mm or CI ＜-1.0 can be used as a threshold for identifying TIC.The diagnosis of TIC and the guidance transfusion for TIC patients by TEG is beneficial.

Progresses in understanding trauma-induced coagulopathy and the underlying mechanism / 中华创伤杂志(英文版)

Trauma-induced coagulopathy (TIC) is a clinical syndrome caused by imbalance between clotting, anti-coagulation and fibrinolysis resulting from multiple pathological factors such as hemorrhage and tissue injury in the early stage of trauma, and is closely related to the outcome of trauma patients. It is proved in growing evidence that the endogenous coagulation disturbance in trauma itself is the activating factor of TIC, rather than dilution or other acquired coagulopathy. Therefore, a thorough understanding of the molecular mechanisms in the pathogenesis and progression is crucial for effective prevention and treatment in patients with TIC. This review focuses on transitions in the concept of TIC and mechanical progress.

Risk factors and clinical effects of trauma induced coagulopathy in ICU patients with major trauma / 中华急诊医学杂志

Objective To investigate the risk factors of trauma induced coagulopathy and its effect on the outcome of ICU patients with severe trauma.Methods Totally 223 severe trauma patients admitted to emergency ICU within 24h after injuring between June,2008 and September,2009 were retrospectively analyzed.Injury severity score (ISS),APACHE Ⅱ score,coagulation function,routine blood test,biochemical test,and blood gas assay were completed for each patient. Hypoperfusion was defined as vasoactive agents usage,or base deficit (BD) ≥ 6 or shock index ≥ 1. Patients were divided into coagulopathy group and non-coagulopathy (control) group according to coagulation function.ISS,APACHE Ⅱ score,the occurrence of hypothermia and hypoperfusion were compared between the two groups.The risk factors of trauma induced coagulopathy were analyzed,and the multivariate logistic regression equation was formulated.Coagulation function and incidence of trauma induced coagulopathy were compared between nonsurvival and survival group.Results Fifty-two of 223 (23.3 ％ ) patients met the criteria of trauma induced coagulopathy.Mortality rate in this group was significantly higher than that in non-coagulopathy group (36.5％ vs 9.4％, P ＜ 0.01 ). Patients in both groups had the comparability in age,sex, injury mechanism and time after trauma.ISS,the incidence of hypothermia,hypoperfusion and severe traumatic brain injury in coagulopathy group were higher than those in non-coagulopathy group ( P ＜ 0.01 ).GCS,hemoglobin,hematocrit,and platelet counts in coagulopathy group were significantly lower than that in noncoagulopathy group (P＜ 0.01).Base deficit ≥6,GCS ≤ 8,and platelet counts were considered as the independent risk factors involved in trauma- induced coagulopathy according to logistic regression in this study.Coagulation function of non-survivors also remarkably attenuated when compared with survival group.Conclusions The incidence rate of trauma induced coagulopathy is high in severe trauma patients admitted to ICU within 24h. Trauma induced coagulopathy correlates well with ISS core,severe traumatic brain injury,shock and hypothermia,and results in high mortality.