Predicting Life-threatening Coagulopathy in the Massively Transfused Trauma Patient

TLDR

Recalcitrant coagulopathy, the “bloody vicious cycle,” accounts for most deaths after torso trauma. The study aims to develop a predictive model for this life‑threatening complication to aid clinical decision‑making. Prospectively, 58 massive‑transfusion patients were evaluated, and a logistic regression identified pH < 7.10, temperature < 34 °C, ISS > 25, and systolic BP < 70 mmHg as independent predictors of coagulopathy. The model predicts 39–49% risk with two risk factors, rising to 98% when all four are present, confirming that persistent hypothermia and metabolic acidosis drive post‑injury coagulopathy.

Abstract

Background Recalcitrant coagulopathy "the bloody vicious cycle," produces the majority of deaths after torso trauma. A model predicting this life-threatening complication may facilitate clinical decision-making. Methods We prospectively analyzed patients > 15 years old who received a massive transfusion (> 10 units of packed red blood cells (PRBC)/24 h) over a 2-year period. Excluding massive head injuries and pre-existing disease, the 58 study patients had a mean age = 35.4 years, Injury Severity Score (ISS) = 30.6, and PRBC = 24.2 units/24 h. Results Defined as prothrombin time of two times that of normal laboratory controls and partial thromboplastin time as two times that of normal laboratory controls, 27 patients (47%) developed life-threatening coagulopathy. Using a multiple logistic regression model, the four significant risk factors (with odds ratio) were (1) pH < 7.10 (12.3), (2) temperature < 34degreesC (8.7), (3) ISS > 25 (7.7), and (4) systolic blood pressure < 70 mm Hg (5.8). The conditional probability of developing coagulopathy was ISS > 25 + systolic blood pressure < 70 mm Hg = 39%, ISS > 25 + temperature < 34degreesC = 49%, ISS > 25 + pH < 7.10 = 49%; with all four risk factors the incidence was 98%. Conclusion Postinjury life-threatening coagulopathy in the seriously injured requiring massive transfusion is predicted by persistent hypothermia and progressive metabolic acidosis.