Abstract
BACKGROUND: The aim of this study was to test the hypothesis that severely injured trauma
patients would be hypercoagulable compared with controls measured by thromboelastography and that
this hypercoagulability would persist over a broad range of temperatures.
METHODS: A prospective study evaluating the effects of temperature on coagulation in trauma
patients with Injury Severity Scores 15 and controls was completed. Thromboelastography was
performed 24 hours after admission at 4 temperatures ranging from 32C to 38C.
RESULTS: Ninety-two subjects (46 patients) were analyzed. Patients had a median Injury Severity
Score of 20 (interquartile range, 16 26). Time to clot formation increased (P .001) and fibrin
cross-linking decreased (P .01) in both groups as temperature decreased. Between groups, time to
clot formation, fibrin cross-linking, and clot strength were significantly different at each temperature
(P .01), with patients being more hypercoagulable. Time to clot formation and fibrin cross-linking
were more affected by temperature in controls compared with patients (P .02).
CONCLUSIONS: Severely injured patients are more hypercoagulable than controls throughout a
broad range of temperature. Decreasing temperature has a greater effect on coagulation in controls
compared with patients.
2011 Elsevier Inc. All rights reserved.
Hemorrhage continues to be the leading cause of preventable death in trauma patients.1 Studies have shown that
the triad of hypothermia, acidosis, and coagulopathy contribute significantly to the severity of hemorrhage and rate
of mortality.2 6 Current methods of estimating coagulopathy include the prothrombin time (PT) and partial thromboplastin time (PTT). Human studies by Gubler et al7 and
Reed et al8 showed prolonged PT and PTT at lower temperatures. PT and PTT are poor indicators of in vivo coag* Corresponding author. Tel.: 503-494-3500; fax: 503-494-6519.
E-mail address: schreibm@ohsu.edu
Manuscript received November 9, 2010; revised manuscript January
21, 2011
0002-9610/$ - see front matter 2011 Elsevier Inc. All rights reserved.
doi:10.1016/j.amjsurg.2011.01.012
588
Figure 1
study of TEG in hypothermic trauma patients, body temperature 34C correlated with abnormal values on TEG.10
Confounding these findings is the fact that the more hypothermic patients had significantly greater Injury Severity
Scores (ISS) and received more fluid resuscitation than the
less hypothermic patients.11 No study has evaluated the
direct effects of temperature on coagulation in trauma patients as measured by TEG.
Methods
This was a prospective, noninterventional, single-center
study evaluating the effects of temperature on coagulation
measured by TEG in normal control subjects and in severely
injured trauma patients. All trauma patients with ISS 15
were eligible to be enrolled in the study. Patients were
excluded from eligibility for the following reasons: current
use of therapeutic anticoagulation, preexisting coagulopathy, pregnancy, or inability to obtain consent from either the
patient or a legal authorized representative. Patients and
controls were consented before enrollment in the study.
Controls were age and gender matched to patients.
Statistical analysis
Statistical analyses were performed using SPSS version
18.0 (SPSS, Inc, Chicago, IL). For normally distributed
data, an analysis of variance and Students t test were used
TEG assay
Table 1
Demographics
Variable
Patients
Controls
Age (y)
Men
Women
ISS
48 (3164)
23
23
20 (1626)
38 (3350)
23
23
No data
589
Results
Comments
Table 2
Thromboelastographic data
Variable
Fibrin cross-linking
Patients
Controls
Lysis
Patients
Controls
32C
34C
36C
38C
62.7 (57.466.4)*
54.1 (48.457.5)*
63.4 (59.267.3)*
57.0 (52.360.9)*
67.1 (63.470.6)*
57.7 (53.261.7)*
67.8 (62.569.9)*
61.6 (55.965.3)*
.05 (.00.50)
.15 (.001.50)
.30 (.001.03)
.20 (.00.75)
.95 (.201.60)
.50 (.101.30)
1.20 (.502.65)
1.75 (.703.30)
590
Conclusions
Hypothermia is associated with increased time to clotting
and decreased fibrin cross-linking in both severely injured
trauma patients and controls. Stabilized trauma patients are
more hypercoagulable than controls with respect to all aspects of clotting as measured by TEG regardless of temperature. Hypercoagulability in severely injured trauma patients is relatively resistant to hypothermia compared with
controls.
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Discussion
Robert M. Rush, M.D. (Tacoma, WA): When a bleeding and sick trauma patient enters the resuscitation bay, the
last thing one thinks of is hypercoagulation. Usually it is the
opposite: Lets get this bleeding stopped! The authors
591