Trauma Resuscitation Consideration: Sex Matters

Abstract

Background-Sex dimorphisms in coagulation have been recognized but whole blood assessment of these dimorphisms and their relationship to outcomes in trauma have not been investigated. This study characterizes the viscoelastic hemostatic profile of severely injured patients by sex and examines how sex-specific coagulation differences affect clinical outcomes, specifically massive transfusion (MT) and death. We hypothesize that severely injured females are more hypercoagulable and thus, have lower rates of MT and mortality.Study Design-Hemostatic profiles and clinical outcomes from all trauma activation patients from two Level I trauma centers were examined with sex as an experimental variable. As part of a prospective study, whole blood was collected and thrombelastography (TEG) was performed. Coagulation profiles were compared between sexes and association with MT and mortality were examined. Poisson regression with robust standard errors was performed.Results-Overall, 464 patients (23% female) were included. By TEG, females had a more hypercoagulable profile, with a higher angle (clot propagation) and maximum amplitude (MA, clot strength). Females were less likely to present with hyperfibrinolysis or prolonged activating clotting time than males. In the setting of depressed clot strength (abnormal MA), female sex

Viscoelastic monitoring in trauma resuscitation

“…In addition to environmental factors and ethanol, sex and age also contribute to discrepancies in coagulation profiles. Recent work has demonstrated a mortality impact of sex differences in coagulation profiles with females demonstrating a more hypercoagulable profile and survival benefit in the setting of depressed clot strength 184 . As discussed above, investigations of VEM in pediatric patients are relatively limited in comparison to adults; extrapolating findings from adult studies to the care of pediatric trauma patients should be done with caution.…”

Predictors of new‐onset atrial fibrillation in geriatric trauma patients

“…Schoenberg et al demonstrated that women tend to die soon after trauma and therefore would not have time to develop complications such as atrial fibrillation . It has also been shown in several studies that women have a more hypercoagulable profile and greater hemodynamic tolerance to shock than men, leading them to need less fluid resuscitation . In a 59‐year meta‐analysis looking specifically at the role of sex in atrial fibrillation, Michelena et al found higher rates of lone atrial fibrillation in male patients.…”

Sex- and Gender-Related Factors in Blood Product Transfusions

“…Current transfusion protocols in trauma do not use sex-specific guidelines, and even the TEG based resuscitation protocols were established in a predominantly male population. 25 Therefore, it is somewhat unsurprising that despite using resuscitation protocols guided by nearly real-time data on coagulation profiles, there was no sex difference in the amount of blood product given in the study by Coleman et al 20 Females may be overly resuscitated with certain blood products under current protocols, which can have significant consequences including thromboembolic events. Prior to modern DCR, a greater amount of crystalloids were given in massive hemorrhage, and aggressive volume resuscitation with crystalloids can lead to coagulopathy, for which females have twice the mortality.…”

“…For instance, sex differences in physiology as fundamental as the relative quantity of proteins comprising apheresis platelets have been observed, 19 and we know there are also clinically significant sex differences in hemostatic response to trauma, with females being more hypercoagulable. 20,21 The prevailing modern resuscitation strategy in traumatic hemorrhage, which was borne from military studies predominantly using young men, is called Damage Control Resuscitation (DCR) and involves giving blood products early and aggressively in high ratios (1:1:1 or 1:1:2 of plasma: platelets: RBC) while limiting crystalloid use. At least 2 studies have found mortality differences based on recipient sex, and the ratio of blood products they are resuscitated with.…”

“…18,21 A noteworthy study by Coleman et al looked at sex as a specific variable and used thromboelastography (TEG), a fast, comprehensive, and accurate measure of coagulation profiles to guide resuscitations in nearly real time. 20 They analyzed the coagulation profiles of 464 patients who required trauma activations in 2 American emergency departments while noting the mortality and quantity of blood products given. Females had greater clot formation and clot strength, were less hyperfibrinolytic, less likely to have prolonged activating clotting time at presentation, and in the setting of reduced clot strength females were more likely to survive.…”