Early Predictive Factors of Hypofibrinogenemia in Acute Trauma Patients

The utility of the prehospital shock index, age shock index, and modified shock index for predicting hypofibrinogenaemia in trauma patients: an observational retrospective study

PURPOSE

Reduced fibrinogen levels are associated with worse outcomes in bleeding trauma patients. The purpose of this study was to evaluate the potential of the prehospital shock index (SI) and its derivatives, the age shock index (aSI) and the modified shock index (mSI), as predictors of hypofibrinogenaemia in trauma patients.

METHODS

This retrospective study included 2383 patients who presented to a regional trauma center. We reviewed the plasma fibrinogen levels upon admission to the trauma center and patients were divided into two groups: the hypofibrinogenaemia group and the normal group. The predictive performances of the SI, aSI, and mSI were assessed by the area under the receiver operating characteristic curve (AUC).

RESULTS

Of the 2383 patients, 235 (9.9%) had hypofibrinogenaemia. Patients with hypofibrinogenaemia were more likely to receive transfusions within 4 h and had significantly greater in-hospital mortality than patients with normal fibrinogen levels. The AUCs of prehospital SI, prehospital aSI, and prehospital mSI for the prediction of hypofibrinogenaemia were 0.75 (95% confidence interval [CI] 0.73-0.77), 0.70 (95% CI 0.68-0.72), and 0.75 (95% CI 0.73-0.77), respectively.

CONCLUSION

Prehospital SI and prehospital mSI demonstrated moderate performance for identifying trauma patients with hypofibrinogenaemia. The prehospital aSI had poor predictive performance. In the prehospital setting, the use of prehospital SI or prehospital mSI as the sole predictor of hypofibrinogenaemia in trauma patients is not recommended.

Trauma-Induced Coagulopathy: Overview of an Emerging Medical Problem from Pathophysiology to Outcomes

Coagulopathy induced by major trauma is common, affecting approximately one-third of patients after trauma. It develops independently of iatrogenic, hypothermic, and dilutive causes (such as iatrogenic cause in case of fluid administration), which instead have a pejorative aspect on coagulopathy. Notwithstanding the continuous research conducted over the past decade on Trauma-Induced Coagulopathy (TIC), it remains a life-threatening condition with a significant impact on trauma mortality. We reviewed the current evidence regarding TIC diagnosis and pathophysiological mechanisms and summarized the different iterations of optimal TIC management strategies among which product resuscitation, potential drug administrations, and hemostatis-focused approaches. We have identified areas of ongoing investigation and controversy in TIC management.

Prevalence of Acute Traumatic Coagulopathy in Acutely Traumatized Dogs and Association with Clinical and Laboratory Parameters at Presentation

OBJECTIVE

 The aim of this study was to determine the prevalence of acute traumatic coagulopathy (ATC) and identify associated clinical and laboratory parameters including rotational thromboelastometry.

STUDY DESIGN

 Dogs presenting within 6 hours after trauma were allocated to the ATC or non-ATC group based on thromboelastometry analysis (ex-tem S, in-tem S, fib-tem S). ATC was defined as ≥2 hypocoagulable parameters in 1 profile and ≥ 1 hypocoagulable parameter in an additional profile. Parameters used were ex-tem and in-tem clotting time (CT), clot formation time (CFT), maximum clot firmness (MCF), maximum lysis and fib-tem MCF. Clinical and laboratory parameters at presentation, animal trauma triage (ATT) score, transfusion requirement and outcome were compared. Logistic regression was used to identify independent factors associated with ATC.

RESULTS

 Eleven of 33 dogs presented with ATC and showed ex-tem CT and CFT prolongation and reduced MCF amplitude in all profiles (all p < 0.001). pH (p = 0.043) and potassium concentration (p = 0.022) were significantly lower and bleeding (p = 0.027) and plasma transfusions (p = 0.001) more common in dogs with ATC. Time after trauma (p = 0.040) and Animal Trauma Triage score (p = 0.038, including haematocrit as confounding factor) were associated with the presence of ATC.

CONCLUSION

 Acute traumatic coagulopathy is more common in traumatized dogs than previously reported. Acute traumatic coagulopathy was associated with acidosis, Animal trauma triage score, time after trauma and higher transfusion needs. Coagulation abnormalities include ex-tem CT and CFT prolongations and decreased clot strength.

Sintilimab, a PD-1 Inhibitor, Completely Reversed Rarely Refractory Hypofibrinogenemia in a Gastric Cancer Patient: A Case Report and Review of the Literature

While cancer is often related to hyperfibrinogenemia, it is rarely related to hypofibrinogenemia. Specifically, gastric cancer concomitant with unprovoked hypofibrinogenemia and the corresponding treatment approach have been rarely reported. We presented a case of gastric cancer in a 78-year-old Chinese woman in whom sudden, unprovoked refractory hypofibrinogenemia had been found during the whole brain radiotherapy despite stable clinical condition. Fibrinogen supplementation was not useful for controlling her level of fibrinogen. However, when she received sintilimab, an immunotherapy drug acting as programmed death receptor 1 inhibitor, to treat her gastric cancer, fibrinogen rose to the normal level. We also reviewed the literature to explore the causes of hypofibrinogenemia in tumor patients. This case suggests that we need to pay attention to tumor-related coagulation disorders, and monitoring coagulation indicators is essential. Treating primary disease by immunotherapy drugs may be an important method to improve the level of coagulation factors. This is the first report of sintilimab reversing a rare refractory hypofibrinogenemia in a patient with gastric cancer.

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

BACKGROUND

Severe traumatic injury continues to present challenges to healthcare systems around the world, and post-traumatic bleeding remains a leading cause of potentially preventable death among injured patients. Now in its fifth edition, this document aims to provide guidance on the management of major bleeding and coagulopathy following traumatic injury and encourages adaptation of the guiding principles described here to individual institutional circumstances and resources.

METHODS

The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma was founded in 2004, and the current author group included representatives of six relevant European professional societies. The group applied a structured, evidence-based consensus approach to address scientific queries that served as the basis for each recommendation and supporting rationale. Expert opinion and current clinical practice were also considered, particularly in areas in which randomised clinical trials have not or cannot be performed. Existing recommendations were re-examined and revised based on scientific evidence that has emerged since the previous edition and observed shifts in clinical practice. New recommendations were formulated to reflect current clinical concerns and areas in which new research data have been generated.

RESULTS

Advances in our understanding of the pathophysiology of post-traumatic coagulopathy have supported improved management strategies, including evidence that early, individualised goal-directed treatment improves the outcome of severely injured patients. The overall organisation of the current guideline has been designed to reflect the clinical decision-making process along the patient pathway in an approximate temporal sequence. Recommendations are grouped behind the rationale for key decision points, which are patient- or problem-oriented rather than related to specific treatment modalities. While these recommendations provide guidance for the diagnosis and treatment of major bleeding and coagulopathy, emerging evidence supports the author group's belief that the greatest outcome improvement can be achieved through education and the establishment of and adherence to local clinical management algorithms.

CONCLUSIONS

A multidisciplinary approach and adherence to evidence-based guidance are key to improving patient outcomes. If incorporated into local practice, these clinical practice guidelines have the potential to ensure a uniform standard of care across Europe and beyond and better outcomes for the severely bleeding trauma patient.