An International Normalized Ratio–Based Definition of Acute Traumatic Coagulopathy Is Associated With Mortality, Venous Thromboembolism, and Multiple Organ Failure After Injury

Abstract

Objective Acute traumatic coagulopathy (ATC) is associated with adverse outcomes including death. Previous studies examining ATC's relationship with mortality are limited by inconsistent criteria for syndrome diagnosis, inadequate control of confounding and single-center designs. In this study, we validated the admission international normalized ratio (INR) as an independent risk factor for death and other adverse outcomes after trauma and compared two common INR-based definitions for ATC. Design Multicenter prospective observational study. Setting Nine level I trauma centers in the United States. Patients 1,031 blunt trauma patients with hemorrhagic shock. Interventions None. Measurements and Main Results INR exhibited a positive adjusted association with all-cause in-hospital mortality, hemorrhagic shock-associated in-hospital mortality, venous thromboembolism, and multiple organ failure. ATC affected 50% of subjects if defined as an INR >1.2 and 21% of subjects if defined by INR >1.5. After adjustment for potential confounders, ATC defined as an INR >1.5 was significantly associated with all-cause death (OR 1.88, p<0.001), hemorrhagic shock-associated death (OR 2.44, p=0.001), venous thromboembolism (1.73, p<0.001), and multiple organ failure (OR 1.38, p=0.02). ATC defined as an INR >1.2 was not associated with an increased risk for the studied outcomes. Conclusions Elevated INR on hospital admission is a risk factor for mortality and morbidity after severe trauma. Our results confirm this association in a prospectively-assembled multicenter cohort of severely injured patients. Defining ATC using an INR >1.5 but not an INR >1.2 identified a clinically-meaningful subset of trauma patients who, adjusting for confounding factors, suffered more adverse outcomes. Targeting future therapies for ATC to patients with an INR >1.5 may yield greater returns than using a lower INR threshold.

Elevated admission international normalized ratio strongly predicts mortality in victims of abusive head trauma

“…Tests of coagulation including international normalized ratio (INR) have been shown to be a marker of poor prognosis in adult and pediatric accidental trauma patients, although the majority of research has been conducted in adults. [13][14][15][16][17][18][19][20][21][22][23][24] The mechanism of acute traumatic coagulopathy, prognostic value, and therapeutic targets remain unclear in pediatric trauma patients. The typical patient population in whom pediatric research has been conducted is limited mainly to children with accidental head injury.…”

Tactical damage control resuscitation in austere military environments

“…It has been identified as one of the strongest predictors of the need for massive transfusion in both civilian and military populations 104–106. Many authors suggest to use an increased prothrombin ratio as a definition of coagulopathy, although the cut-off value to define the coagulopathy is still debated with values of 1.2 and 1.5 suggested22 107 with 1.2 seeming more appropriate for the field care context. POC INR testing is nowadays well assessed and allows safe self-monitoring of oral anticoagulation108 109 but its use is still under discussion for patients with trauma110 although several teams have reported a good correlation between POC testing and laboratory testing in such situations 111 112.…”

Development and validation of a prehospital prediction model for acute traumatic coagulopathy

“…Present in up to 30% of severely injured patients on emergency department (ED) arrival, ATC is an endogenous biologic syndrome contributing to, but distinct from, traumatic hemorrhage in general [13–16]. When defined as an international normalized ratio (INR) >1.5 on hospital admission, ATC is associated with a significantly increased risk-adjusted probability of not only all-cause and hemorrhage-associated mortality but also multiple organ failure and venous thromboembolism [13, 14, 17]. As most bleeding-related deaths occur early after injury, treatment to prevent or mitigate ATC also needs to begin quickly, potentially even in the prehospital setting.…”