Early Predictive Factors of Hypofibrinogenemia in Acute Trauma Patients

Abstract

Background:Uncontrolled hemorrhage still remains a major cause of trauma-associated mortality. The events resulting in acute traumatic coagulopathy, particularly hypofibrinogenemia, make control of bleeding difficult. It is essential to timely predict, diagnose, and manage trauma-induced coagulopathy.Aims:The aim of this study is to determine clinical and easily available laboratory variables that are predictive of hypofibrinogenemia in acute trauma patients.Settings and Design:This 2-year retrospective work examined the data of major trauma patients that were referred to Shahid Rajaee Hospital's emergency room in hemorrhagic shock condition.Materials and Methods:Fibrinogen level was assessed for these patients on their arrival at our facility. Along with clinical and routine paraclinical variables, we evaluated the predictive value of these variables for a fibrinogen level below 100 mg/ml.Results:A total of 855 cases were included (females: 16.4%; and males: 83.6%) in the study. The mean ± SD age was 36 ± 17.9 years, and the mean ± SD injury severity score was 12.2 ± 9. Motor vehicle accident was the most common cause of injury. Three factors, including arterial pH (cut off point = 7.34; area under the curve [AUC]: 0.59), base excess (cutoff point = −4.3; AUC: 0.60), and patients' gender had a significant association with the fibrinogen level under 100 mg/ml. When three factors of pH, BE, and patients' gender are being assessed simultaneously, the AUC became 0.62 (the predictive ability improved).Conclusions:Variables, including arterial pH, BE level, and patients' gender have predictive value for fibrinogen transfusion in trauma.

The European guideline on management of major bleeding and coagulopathy following trauma: fifth edition

“…Traumatic coagulopathy is characterised by an increased fibrinolytic activity and a low fibrinogen concentration [ 8 , 22 , 23 , 29 , 226 , 266 , 536 , 587 – 589 ]. Besides early administration of TXA (see recommendation R22) early fibrinogen administration is also of key importance, ideally guided by a fibrinogen concentration < 1.5 g/L or viscoelastic evidence of a functional fibrinogen deficiency [ 41 – 43 , 590 , 591 ].…”

“…Thromboelastometry (TEM) is useful to guide individualised goal-directed coagulation therapy in patients with traumatic coagulopathy [ 17 , 560 , 610 , 611 ]. In the initial phase, a low fibrinogen concentration is expected [ 8 , 22 , 23 , 29 , 226 , 266 , 536 , 587 – 589 ]. However, thrombin generation is preserved or even increased [ 612 , 613 ].…”

“…Interestingly, in accord with this, Ohmori et al found that, unlike young people, those > 65 years, had higher fibrinogen levels following major blood loss, suggesting that fibrinogen level is a poor early indicator of blood loss in the older population [ 643 ]. Schlimp et al and others have demonstrated that fibrinogen levels upon admission strongly correlate with rapidly obtainable routine laboratory parameters such as Hb and BE [ 226 , 589 ]. Fibrinogen levels lower than 1.5 g/L were detected in as many as 73% of trauma patients with an admission Hb lower than 100 g/L and in 63% of those with a BE lower than − 6 [ 644 ].…”

Trauma-Induced Coagulopathy: Overview of an Emerging Medical Problem from Pathophysiology to Outcomes

“…This increased secretion leads to the activation of endothelial cells, resulting in the release of tPA and Weibel–Palade bodies [ 25 ]. These factors bind to the endothelium, induce the release of von Willebrand factor, and encourage platelet recruitment [ 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 ].…”

Sintilimab, a PD-1 Inhibitor, Completely Reversed Rarely Refractory Hypofibrinogenemia in a Gastric Cancer Patient: A Case Report and Review of the Literature

“…The additional mechanism of hypofibrinogenemia in primary hemophagocytic lymphohistiocytosis (HLH) is uptake of fibrin and/or fibrinogen by activated histiocytes (15). Thirdly, hypofibrinogenemia is an important component of acute traumatic coagulopathy (16). Previous studies have shown that fibrinolytic activity increased in trauma patients after injury, which impaired the ability to control bleeding (17).…”