Early Identification of Acute Traumatic Coagulopathy Using Clinical Prediction Tools: A Systematic Review

Abstract

Background and objectives: Prompt identification of patients with acute traumatic coagulopathy (ATC) is necessary to expedite appropriate treatment. An early clinical prediction tool that does not require laboratory testing is a convenient way to estimate risk. Prediction models have been developed, but none are in widespread use. This systematic review aimed to identify and assess accuracy of prediction tools for ATC. Materials and Methods: A search of OVID Medline and Embase was performed for articles published between January 1998 and February 2018. We searched for prognostic and predictive studies of coagulopathy in adult trauma patients. Studies that described stand-alone predictive or associated factors were excluded. Studies describing prediction of laboratory-diagnosed ATC were extracted. Performance of these tools was described. Results: Six studies were identified describing four different ATC prediction tools. The COAST score uses five prehospital variables (blood pressure, temperature, chest decompression, vehicular entrapment and abdominal injury) and performed with 60% sensitivity and 96% specificity to identify an International Normalised Ratio (INR) of >1.5 on an Australian single centre cohort. TICCS predicted an INR of >1.3 in a small Belgian cohort with 100% sensitivity and 96% specificity based on admissions to resuscitation rooms, blood pressure and injury distribution but performed with an Area under the Receiver Operating Characteristic (AUROC) curve of 0.700 on a German trauma registry validation. Prediction of Acute Coagulopathy of Trauma (PACT) was developed in USA using six weighted variables (shock index, age, mechanism of injury, Glasgow Coma Scale, cardiopulmonary resuscitation, intubation) and predicted an INR of >1.5 with 73.1% sensitivity and 73.8% specificity. The Bayesian network model is an artificial intelligence system that predicted a prothrombin time ratio of >1.2 based on 14 clinical variables with 90% sensitivity and 92% specificity. Conclusions: The search for ATC prediction models yielded four scoring systems. While there is some potential to be implemented effectively in clinical practice, none have been sufficiently externally validated to demonstrate associations with patient outcomes. These tools remain useful for research purposes to identify populations at risk of ATC.

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

“…2,29,30 Several clinical parameters have been proposed to be associated with acute traumatic coagulopathy in people and different acute traumatic coagulopathy scoring systems were subsequently evaluated. 31 In our study, significant bleeding at presentation was the only clinical parameter that was significantly different between dogs with and without acute traumatic coagulopathy and as shown in preceding studies in veterinary and human medicine, dogs in our study population required more plasma transfusions when presenting with acute traumatic coagulopathy. 1,6,7 In contrast to studies in people that report higher mortality in traumatized patients with acute traumatic coagulopathy 13 and a recent study in dogs, 7 survival to hospital discharge was not significantly different between dogs presenting with and without acute traumatic coagulopathy.…”

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

“…The usefulness of protocols for massive hemotransfusion and the need for bedside clotting analyzers have also been demonstrated. The European guidelines currently recommend to directly transfer patients to an appropriate trauma center for treatment and to follow a restricted volume replacement strategy during initial resuscitation [ 1 , 2 , 3 , 5 , 6 , 7 , 8 , 9 , 10 , 11 , 101 , 121 , 122 , 151 , 154 , 161 , 162 , 163 , 164 , 165 , 166 , 167 , 168 , 169 , 170 ]. Blood product optimal use procedures continue to evolve, and their development should be goal directed.…”

Ex vivo hemostatic and immuno‐inflammatory profiles of freeze‐dried plasma

“…Despite advances in understanding, monitoring, and control of hemostasis in trauma, 2,3 outcomes from severe hemorrhage remain poor, with mortality rates approaching 50% for bleeding patients who require massive blood transfusion or who develop a significant coagulopathy. 4,5 Plasma transfusion is the current standard-of-care for treating trauma-induced coagulopathy (TIC). [6][7][8] Plasma is a critical component in damage-control resuscitation, which advocates avoiding crystalloid and colloid, and reintroduces blood components as primary resuscitation fluids for severely injured casualties in the setting of permissive hypotension.…”

“…Up to half of deaths resulting from hemorrhage occur before reaching definitive care. Despite advances in understanding, monitoring, and control of hemostasis in trauma, 2,3 outcomes from severe hemorrhage remain poor, with mortality rates approaching 50% for bleeding patients who require massive blood transfusion or who develop a significant coagulopathy 4,5 …”