High D-Dimer Levels Predict a Poor Outcome in Patients with Severe Trauma, Even with High Fibrinogen Levels on Arrival

Abstract

Elevated D-dimer level in trauma patients is associated with tissue damage severity and is an indicator of hyperfibrinolysis during the early phase of trauma. To investigate the interacting effects of fibrinogen and D-dimer levels on arrival at the emergency department for massive transfusion and mortality in severe trauma patients in a multicenter retrospective study. This study included 519 adult trauma patients with an injury severity score ≥16. Patients with ≥10 units of red cell concentrate transfusion and/or death during the first 24 h were classified as having a poor outcome. Receiver operating characteristic curve analysis for predicting poor outcome showed the optimal cut-off fibrinogen and D-dimer values to be 190 mg/dL and 38 mg/L, respectively. On the basis of these values, patients were divided into four groups: low D-dimer (<38 mg/L)/high fibrinogen (>190 mg/dL), low D-dimer (<38 mg/L)/low fibrinogen (≤190 mg/dL), high D-dimer (≥38 mg/L)/high fibrinogen (>190 mg/dL), and high D-dimer (≥38 mg/L)/low fibrinogen (≤190 mg/dL). The survival rate was lower in the high D-dimer/low fibrinogen group than in the other groups. Moreover, the survival rate was lower in the high D-dimer/high fibrinogen group than in the low D-dimer/high fibrinogen and low D-dimer/low fibrinogen groups. High D-dimer level on arrival is a strong predictor of early death or requirement for massive transfusion in severe trauma patients, even with high fibrinogen levels.

Dynamics of fibrinogen in acute phases of trauma

“…However, recent guidelines have suggested that concentrations should be maintained over 1.5-2.0 g/L in severe trauma patients [11]. Furthermore, several retrospective studies indicated that fibrinogen levels ≤1.9 g/L on emergency department admission were independent predictors for massive bleeding and death [6,12]. Based on these findings, the appropriate critical plasma fibrinogen threshold will be 2.0 g/L.…”

“…Critical (≤1.0 g/L) and abnormal (1.0-1.8 g/L) fibrinogen levels were also reported in 21 and 44% of severe trauma patients who required massive transfusions, respectively [8]. Decreased plasma fibrinogen levels on arrival at the emergency department are an independent predictor of massive transfusion requirement and death in severe trauma patients [5][6][7][8][9].…”

“…In severe trauma, elevations in D-dimer and FDP levels are frequently observed and are complicated with coagulopathy, regardless of severe shock [6,12,16,[54][55][56][57][58][59]. Although severe head trauma is not generally complicated with shock, trauma-induced coagulopathy is frequently observed with this type of injury [54,[56][57][58].…”

“…Furthermore, plasma fibrinogen levels deteriorate more frequently and earlier than other routine coagulation parameters (prothrombin time, activated partial thromboplastin time, and platelet count) in severe trauma patients [5]. In a Japanese multicenter retrospective study, 25% of severe trauma patients (Injury Severity Score ≥ 16) had decreased plasma fibrinogen concentrations on arrival at the emergency department [6]. Critical (≤1.0 g/L) and abnormal (1.0-1.8 g/L) fibrinogen levels were also reported in 21 and 44% of severe trauma patients who required massive transfusions, respectively [8].…”

“…In cases of severe trauma, depleted plasma fibrinogen levels are frequently observed before dilution by infusion [5][6][7][8][9]. Furthermore, plasma fibrinogen levels deteriorate more frequently and earlier than other routine coagulation parameters (prothrombin time, activated partial thromboplastin time, and platelet count) in severe trauma patients [5].…”