INTRODUCTION
RESULTS
Severe trauma can cause life-threatening hemorrhage. This
rare condition is worsened by the fact that actively bleeding
trauma patients quickly develop trauma induced
coagulopathy TIC. Thought to be the consequence of the
“lethal
triad”
old
concept
(hypothermia,
dilution,
coagulopathy), this acute coagulopathy is in fact a more
complex phenomenon and occurs at the early phase after
trauma.
Between January 2012 and April 2013, 82 patients have been
included in the study.
All patients with TICCS >=10 had a hypocoagulable status both in
conventional coagulation tests and thromboelastometric assays. In
contrast, patients with TICCS<10 don’t suffer from coagulopathy.
90,9% of the patients with TICCS>=10 were diagnosed with
hemorrhagic shock. 60% of them required urgent surgical
haemostasis and massive transfusion (defined by the use of more
than 10 units of RBC within the firsts 24 hours), the other 40% died
before they could benefit from it.
Only one patient out of 71 with TICCS<10 was diagnosed with
hemorrhagic shock. He needed urgent surgical haemostasis and
transfusion of a small amount of blood products.
Table 2: TICCS regarding categorization in “severe” = the association of all
the 4 following conditions: active bleeding + acute coagulopathy + need
for massive transfusion + need for emergent surgery and “non severe” =
patient without this association.
These results are summarized in table 1 below.
DISCUSSION
Bleeding trauma patients with TIC need extraordinary
therapeutic measures consisting in emergent damage control
surgery, damage control hemostatic resuscitation with
massive transfusion, use of hemostatic agents, permissive
hypotension and highly specific and qualified technical and
human resources at patient’s arrival in the resuscitation room.
And to be efficient, all those strategies, often called Damage
Control Resuscitation DCR, need to be applied as early as
possible.
In order to identify bleeding and coagulopathic trauma
patients before hospital admission, we have developed an
easy-to-measure purely clinical score (the TICCS) aiming at
“flagging” patients with TIC on the site of injury. In contrast to
currently available trauma scoring systems, our score can be
calculated by paramedics in less than 1 min and then
communicated to the hospital allowing taking the necessary
organisational measures before patient’s arrival.
THE TICCS
The TICCS ranges from 0 to18. It is a 3-item based score
considering (I) the severity of trauma (for 2 points), (II) its
hemodynamic repercussions (for 5 points) and (III) the extent
of the body injury (for 11 points).
- 2 points are attributed if the patient is judged critical. If he
isn’t, no point is attributed.
- The patient gets 5 points if his pre-hospital systolic blood
pressure is below 90 mmHg. 0 if SBP is always above 90
mmHg.
- 11 points are attributed for the extent of body injury,
distributed like this: 1 point for head and neck, 1 point for
each extremity, 2 points for the torso region, 2 points for
abdominal region and 2 points for the pelvic region.
Variable
Number
ISS
Blunt trauma
Death within 1 hour
24h survival
30days survival
HR (/min)
SBP (mmHg)
Temperature (°C)
pH
SBE (mmol/l)
Hb H0 (g/l)
INR H0
INR H3
Fibrinogen H0 (g/l)
Fibrinogen H3 (g/l)
Platelets count H0
EXTEM (% with
TICCS<10
71
13.9 (4-43)
92.9%
0
70 (98.5%)
67 (94.3%)
84 (60-130)
135 (75-200)
36.2 (34.8-37.0)
7.33 (7.20-7.40)
- 1.7 (-10-+2.5)
13.9 (8.9-16.7)
1.10 (1.0-2.90)
1.15 (1.0-2.1)
2.8 (0.4-5.2)
3.1 (0.8-8.5)
237000(113000-378000)
2.3%
TICCS>=10
11
45.3 (29-66)
100%
2 (18%)
5 (45.4%)
5 (45.4%)
123 (95-140)
75 (60-85)
34.7 (34-35.9)
7.12 (6.90-7.35)
- 7.9 (-16 - -0.2)
11.8 (6.7-15.6)
1.37 (1.0-2.8)
1.42 (1.0-1.9)
2.1 (0.6-6.4)
1.56 (0.7-3.1)
199300(114000-251000)
100%
13.9%
100%
7%
63.6%
0.61 (0-3)
0.15 (0-3)
0
0
1.4%(1)
6.7 (0-12)
4.6 (0-11)
0.36 (0-1)
54.5%
90.9 % (10)
Our results suggest that the TICCS is a performing and easy-to-use tool to
identify trauma patients suffering from active bleeding and acute
coagulopathy at the very early phase of their management. This could allow
general emergency departments to prepare the specific and extraordinary
measures to care those patients.
TICCS < 10
NO NEED FOR DCR
coagulopathy)
FibTEM (% with
coagulopathy)
Urgent surgical
hemostasis (%)
RBC (24h), units
FFP (24h), units
PC (24h), units
MT (%)
Diagnosis of
haemorrhagic shock
TICCS >= 10
RED FLAG
ACTIVE BLEEDING +
ACUTE
COAGULOPATHY
NEED FOR DCR
- PHONE CONTACT WITH
THE BLOOD BANK
-> MTP ACTIVATION
-> THAWING OF FFP
(%)
1
1
1
2
2
2
- PHONE CONTACT WITH
THE OR
Table1: Summary of Results
- TRAUMA TEAM
(DOCTORS&NURSES)
CALLED IN THE
RESUSCITATION ROOM
1
1
BODY INJURIES ? 11 POINTS
CRITICAL ? YES: 2 POINTS
NO: 0 POINT
SBP < 90 MMHG: 5 POINTS
> 90 MMHG: 0 POINT
CALL FOR
TRAUMA
PRE
HOSPITAL
TEAM ON
SCENE
PRE HOSPITAL
FLAGGING OF
ACTIVE
BLEEDING
PATIENT USING
TICCS
CONCLUSION
PATIENT’S
ADMISSION IN
RESUSCITATION
ROOM
NEED FOR
DCR
HIGH QUALITY
HUMAN AND
TECHNICAL
RESSOURCES IN
RESUSCITATION
ROOM
Early pre-hospital “flagging” of trauma patients with active
bleeding and TIC could allow general emergency units preparing
the specific resources needed to offer high quality DCR at patient’s
arrival at the emergency unit for the limited number patients
needing it (impact on cost-effectiveness of patient’s support) and
would shorten the time between injury and DCR initiation (impact
on patients’ survival).
BLOOD
PRODUCTS
AVAILABILITY
The TICCS is a easy-to-measure purely clinical score that seems to
be a predictive tool, able to discriminate trauma patients with active
bleeding, TIC and in need for DCR from those without this
aggravating combination.
OPERATION
ROOM’S
AVAILABILITY
Information: [email protected]