The Journal of Pediatrics
Volume 160, Issue 2 , Pages 204-209.e3 , February 2012

Coagulopathy is Prevalent and Associated with Adverse Outcomes in Transfused Pediatric Trauma Patients

  • Jeanne E. Hendrickson, MD

      Affiliations

    • Aflac Cancer Center and Blood Disorders Service, Children's Healthcare of Atlanta, Division of Pediatric Hematology/Oncology, Emory University School of Medicine, Atlanta, GA
    • Department of Pathology and Laboratory Medicine, Center for Transfusion and Cellular Therapies Rollins School of Medicine, Altanta, GA
    • Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University School of Medicine, Atlanta, GA
    • Corresponding Author InformationReprint requests: Jeanne E. Hendrickson, MD, 7105B Woodruff Memorial Building, 101 Woodruff Circle, Atlanta, GA 30322.
  • ,
  • Beth H. Shaz, MD

      Affiliations

    • Department of Pathology and Laboratory Medicine, Center for Transfusion and Cellular Therapies Rollins School of Medicine, Altanta, GA
    • New York Blood Center, New York, NY
  • ,
  • Greg Pereira, BSN, RN, MBA

      Affiliations

    • Department of Pathology, Trauma Services, Blood and Tissue Services, Children's Healthcare of Altanta, GA
  • ,
  • Elizabeth Atkins, RN

      Affiliations

    • Department of Pathology, Trauma Services, Blood and Tissue Services, Children's Healthcare of Altanta, GA
  • ,
  • Karen K. Johnson

      Affiliations

    • Department of Pathology, Trauma Services, Blood and Tissue Services, Children's Healthcare of Altanta, GA
  • ,
  • Gaobin Bao, MPH

      Affiliations

    • Blood and Tissue Services, Children's Healthcare of Altanta, GA
  • ,
  • Kirk A. Easley, MS

      Affiliations

    • Blood and Tissue Services, Children's Healthcare of Altanta, GA
  • ,
  • Cassandra D. Josephson, MD

      Affiliations

    • Aflac Cancer Center and Blood Disorders Service, Children's Healthcare of Atlanta, Division of Pediatric Hematology/Oncology, Emory University School of Medicine, Atlanta, GA
    • Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University School of Medicine, Atlanta, GA

Received 12 May 2011 ,Revised 28 June 2011 ,Accepted 5 August 2011.

References 

  1. Brohi K, Singh J, Heron M, Coats T. Acute traumatic coagulopathy. J Trauma Inj Infect Crit Care. 2003;54:1127–1130
  2. MacLeod J, Lynn M, McKenney MG, Jeroukhimov I, Cohn SM. Predictors of mortality in trauma patients. Am Surg. 2004;70:805–810
  3. MacLeod JB, Lynn M, McKenney MG, Cohn SM, Murtha M. Early coagulopathy predicts mortality in trauma. J Trauma Inj Infect Crit Care. 2003;55:39–44
  4. Rixen D, Raum M, Bouillon B, Schlosser LE, Neugebauer E. [Predicting the outcome in severe injuries: an analysis of 2069 patients from the trauma register of the German Society of Traumatology (DGU)]. Unfallchirurg. 2001;104:230–239
  5. Niles SE, McLaughlin DF, Perkins JG, Wade CE, Li Y, Spinella PC, et al. Increased mortality associated with the early coagulopathy of trauma in combat casualties. J Trauma Inj Infect Crit Care. 2008;64:1459–1463discussion 63-5
  6. Maegele M, Lefering R, Yucel N, Tjardes T, Rixen D, Paffrath T, et al. Early coagulopathy in multiple injury: an analysis from the German Trauma Registry on 8724 patients. Injury. 2007;38:298–304
  7. Ferrara A, MacArthur JD, Wright HK, Modlin IM, McMillen MA. Hypothermia and acidosis worsen coagulopathy in the patient requiring massive transfusion. Am J Surg. 1990;160:515–518
  8. Jurkovich GJ, Greiser WB, Luterman A, Curreri PW. Hypothermia in trauma victims: an ominous predictor of survival. J Trauma. 1987;27:1019–1024
  9. Rixen D, Raum M, Bouillon B, Lefering R, Neugebauer E. Base deficit development and its prognostic significance in posttrauma critical illness: an analysis by the trauma registry of the Deutsche Gesellschaft fur unfallchirurgie. Shock. 2001;15:83–89
  10. Hewson JR, Neame PB, Kumar N, Ayrton A, Gregor P, Davis C, et al. Coagulopathy related to dilution and hypotension during massive transfusion. Crit Care Med. 1985;13:387–391
  11. Gando S. Disseminated intravascular coagulation in trauma patients. Semin Thromb Hemost. 2001;27:585–592
  12. Gando S, Nanzaki S, Morimoto Y, Ishitani T, Kemmotsu O. Tissue factor pathway inhibitor response does not correlate with tissue factor-induced disseminated intravascular coagulation and multiple organ dysfunction syndrome in trauma patients. Crit Care Med. 2001;29:262–266
  13. Brohi K, Cohen MJ, Ganter MT, Matthay MA, Mackersie RC, Pittet JF. Acute traumatic coagulopathy: initiated by hypoperfusion: modulated through the protein C pathway?. Ann Surg. 2007;245:812–818
  14. Hess JR, Brohi K, Dutton RP, Hauser CJ, Holcomb JB, Kluger Y, et al. The coagulopathy of trauma: a review of mechanisms. J Trauma. 2008;65:748–754
  15. Hess JR, Lawson JH. The coagulopathy of trauma versus disseminated intravascular coagulation. J Trauma. 2006;60:S12–S19
  16. Hulka F, Mullins RJ, Frank EH. Blunt brain injury activates the coagulation process. Arch Surg. 1996;131:923–927discussion 7-8
  17. Talving P, Benfield R, Hadjizacharia P, Inaba K, Chan LS, Demetriades D. Coagulopathy in severe traumatic brain injury: a prospective study. J Trauma. 2009;66:55–61discussion -2
  18. Dente CJ, Shaz BH, Nicholas JM, Harris RS, Wyrzykowski AD, Patel S, et al. Improvements in early mortality and coagulopathy are sustained better in patients with blunt trauma after institution of a massive transfusion protocol in a civilian level I trauma center. J Trauma Inj Infect Crit Care. 2009;66:1616–1624
  19. Holcomb JB, Wade CE, Michalek JE, Chisholm GB, Zarzabal LA, Schreiber MA, et al. Increased plasma and platelet to red blood cell ratios improves outcome in 466 massively transfused civilian trauma patients. Ann Surg. 2008;248:447–458
  20. Shaz BH, Dente CJ, Nicholas J, MacLeod JB, Young AN, Easley K, et al. Increased number of coagulation products in relationship to red blood cell products transfused improves mortality in trauma patients. Transfusion. 2010;50:493–500
  21. Cotton BA, Au BK, Nunez TC, Gunter OL, Robertson AM, Young PP. Predefined massive transfusion protocols are associated with a reduction in organ failure and postinjury complications. J Trauma. 2009;66:41–48discussion 8-9
  22. Wafaisade A, Maegele M, Lefering R, Braun M, Peiniger S, Neugebauer E, et al. High plasma to red blood cell ratios are associated with lower mortality rates in patients receiving multiple transfusion (4</=red blood cell units<10) during acute trauma resuscitation. J Trauma. 2011;70:81–88discussion 8-9
  23. Hess JR, Holcomb JB, Hoyt DB. Damage control resuscitation: the need for specific blood products to treat the coagulopathy of trauma. Transfusion. 2006;46:685–686
  24. Cotton BA, Gunter OL, Isbell J, Au BK, Robertson AM, Morris JA, et al. Damage control hematology: the impact of a trauma exsanguination protocol on survival and blood product utilization. J Trauma. 2008;64:1177–1182discussion 82-3
  25. Gunter OL, Au BK, Isbell JM, Mowery NT, Young PP, Cotton BA. Optimizing outcomes in damage control resuscitation: identifying blood product ratios associated with improved survival. J Trauma. 2008;65:527–534
  26. Mace SE, Gerardi MJ, Dietrich AM, Knazik SR, Mulligan-Smith D, Sweeney RL, et al. Injury prevention and control in children. Ann Emerg Med. 2001;38:405–414
  27. CDC. Web-based injury statistics query and reporting system. National Center for Injury Prevention and Control, Centers for Disease Control and Prevention. Available at www.cdc.gov/ncipc/wisqars. Accessed May 1 2011.
  28. Department of Transportation (US) NHTSAN. Traffic safety facts 2006: children. Washington, DC: NHTSA. Available at http://www.nhtsa.dot.gov/pdf/nrd-30/NCSA/TSF2005/810618.pdf. Accessed May 1 2011.
  29. Andrew M. Developmental hemostasis: relevance to thromboembolic complications in pediatric patients. Thromb Haemost. 1995;74:415–425
  30. Concato J, Feinstein AR, Holford TR. The risk of determining risk with multivariable models. Ann Intern Med. 1993;118:201–210
  31. Bryant MS, Tepas JJ, Talbert JL, Mollitt DL. Impact of emergency room laboratory studies on the ultimate triage and disposition of the injured child. Am Surg. 1988;54:209–211
  32. Holmes JF, Goodwin HC, Land C, Kuppermann N. Coagulation testing in pediatric blunt trauma patients. Pediatr Emerg Care. 2001;17:324–328
  33. Miner ME, Kaufman HH, Graham SH, Haar FH, Gildenberg PL. Disseminated intravascular coagulation fibrinolytic syndrome following head injury in children: frequency and prognostic implications. J Pediatr. 1982;100:687–691
  34. Olson JD, Kaufman HH, Moake J, O'Gorman TW, Hoots K, Wagner K, et al. The incidence and significance of hemostatic abnormalities in patients with head injuries. Neurosurgery. 1989;24:825–832
  35. Tude Melo JR, Di Rocco F, Blanot S, Oliveira-Filho J, Roujeau T, Sainte-Rose C, et al. Mortality in children with severe head trauma: predictive factors and proposal for a new predictive scale. Neurosurgery. 2010;67:1542–1547
  36. Hymel KP, Abshire TC, Luckey DW, Jenny C. Coagulopathy in pediatric abusive head trauma. Pediatrics. 1997;99:371–375
  37. Lippi G, Franchini M, Montagnana M, Guidi GC. Coagulation testing in pediatric patients: the young are not just miniature adults. Semin Thromb Hemost. 2007;33:816–820
  38. Andrew M, Vegh P, Johnston M, Bowker J, Ofosu F, Mitchell L. Maturation of the hemostatic system during childhood. Blood. 1992;80:1998–2005
  39. Namias N, McKenney MG, Martin LC. Utility of admission chemistry and coagulation profiles in trauma patients: a reappraisal of traditional practice. J Trauma. 1996;41:21–25
  40. Parish RA, Watson M, Rivara FP. Why obtain arterial blood gases, chest x-rays, and clotting studies in injured children? Experience in a regional trauma center. Pediatr Emerg Care. 1986;2:218–221
  41. Borgman MA, Maegele M, Wade CE, Blackbourne LH, Spinella PC. Pediatric trauma BIG score: predicting mortality in children after military and civilian trauma. Pediatrics. 2011;127:e892–e897
  42. Hindy-Francois C, Meyer P, Blanot S, Marque S, Sabourdin N, Carli P, et al. Admission base deficit as a long-term prognostic factor in severe pediatric trauma patients. J Trauma. 2009;67:1272–1277
  43. Jung J, Eo E, Ahn K, Noh H, Cheon Y. Initial base deficit as predictors for mortality and transfusion requirement in the severe pediatric trauma except brain injury. Pediatr Emerg Care. 2009;25:579–581

 The authors declare no conflicts of interest.

PII: S0022-3476(11)00814-6

doi: 10.1016/j.jpeds.2011.08.019

The Journal of Pediatrics
Volume 160, Issue 2 , Pages 204-209.e3 , February 2012