Abstract
Purpose
In patients with traumatic pelvic fractures, thromboelastography (TEG) is a useful tool to rapidly evaluate and identify coagulation disturbances. The purpose of this study was to examine the coagulation kinetics of patients with traumatic pelvic fractures (pelvic ring and/or acetabulum) by analyzing the TEG results at initial presentation and its relationship with mortality and blood loss.
Methods
A retrospective review at our Level-1 trauma center was conducted to identify Full Trauma Team activations (FTTa) with traumatic pelvic and/or acetabular fractures who were evaluated with a TEG on initial presentation between 2012 and 2016. In-hospital mortality, product transfusion, and hemoglobin changes were analyzed. Subgroup analysis was performed based on pelvic fracture type.
Results
141 patients with a mean age of 49.0 ± 20.8 years and mean Injury Severity Score (ISS) of 25.18 ± 12.8 met inclusion criteria. PRBC transfusion occurred in 78.0% of patients; a total of 1486 blood products were transfused. A total of 65 patients (46.1%) underwent operative treatment for the pelvic injuries, and 18 patients (12.7%) required embolization. The overall in-hospital mortality rate was 14.9%. The degree of clot lysis at 30 min (LY30) was significantly associated with blood loss (p < 0.0001), units of packed red blood cells (PRBCs) transfused (p < 0.0001), and mortality rate (p = 0.0002).
Conclusion
Increased fibrinolysis evidenced by an elevated LY30 on initial TEG in patients with traumatic pelvic fractures is associated with increased blood loss, blood product transfusions, and mortality. Future studies should evaluate the clinical utility of reversing hyperfibrinolysis on initial TEG.
Level of evidence
Prognostic level III.
Keywords: Thromboelastography, Pelvic fractures, Acetabulum fractures, Blood loss, Blood transfusion, Orthopaedic trauma
Introduction
Traumatic pelvic injuries are commonly associated with significant blood loss and hemodynamic instability [1–3]. Hemorrhage associated with these injuries can arise from various sources including exposed cancellous bone of fractured surfaces, disruption of venous structures, or ruptured pelvic vessels. The associated hemorrhage increases the risk of mortality due to exsanguination [3, 4]. Nearly 40% of these patients will require blood transfusion, with a high proportion requiring multiple units of packed red blood cells (PRBCs) [5]. Advances in hemorrhage control, blood management, and the implementation of urgent/emergent angiography have improved management of these patients [6–8]. Despite this progress, most interventions do little to address venous bleeding responsible for more than 85% of hemorrhage in unstable pelvic fractures [7, 9, 10]. As a result, mortality associated with pelvic trauma remains high [2, 3, 6, 11]. While there has been significant focus in the general surgery trauma literature on coagulopathy and its role in hemorrhage and mortality, little attention in the orthopaedic literature has focused on its role in traumatic pelvic injury patients.
Thromboelastography (TEG) is a rapid method for evaluating coagulation kinetics and can identify hypercoagulable and hypocoagulable states. TEG is unique in that it can diagnose and quantify fibrinolysis, allowing clinicians to appropriately use antifibrinolytic drugs and blood products such as cryoprecipitate and fibrinogen concentrate [12]. The use of TEG is becoming increasingly available and is considered part of the standard evaluation for high acuity patients in trauma centers across the country. Reported variables include r, which evaluates time to clot initiation; k, which evaluates speed of clot formation; MA, which evaluates overall clot strength; and LY30, which evaluates the percent clot lysis at 30 minutes (min) [13]. Elevations in the LY30 variable in trauma patients have previously been correlated with increased rates of mortality, and recent evidence suggests that reversal of this parameter results in improved mortality rates in these patients [14, 15].
Identifying patients at risk of blood loss and increased mortality is important for risk stratification, optimization, and timely interventions. The purpose of this study was to examine the coagulation kinetics of patients with traumatic pelvic fractures (pelvic ring and/or acetabulum) by analyzing the TEG results at initial presentation and its relationship with mortality and blood loss.
Patients and methods
After obtaining Institutional Review Board (IRB) approval, the Trauma Registry at our Level-1 trauma center was searched for patients who presented as Full Trauma Team activations (FTTa) with a traumatic pelvic fracture, including acetabulum and pelvic ring fractures, and received thromboelastography (TEG) on admission between January 2012 and September 2016. Patients taking anticoagulants other than aspirin prior to admission were excluded from analysis. Other exclusion criteria included patients less than 18 years of age and patients who presented as Partial Trauma Team activations (PTTa).
As part of the standard trauma evaluation, blood specimens were collected in a citrate tube, transported on ice immediately from the Emergency Department to the clinical laboratory, and given directly to the technician for TEG. Samples were then processed immediately on the calibrated TEG® 5000 Thromboelastograph® (Haemoscope Corporation, Niles, IL) using citrated kaolin to initiate clotting according to the manufacturer’s instructions. Results were reported using the integrated software and the electronic health record. The degree of clot lysis at 30 min (LY30) is the percent reduction in amplitude of clot strength 30 min after maximal amplitude is reached. The change in clot strength over 30 min is a proxy variable for fibrin breakdown [12]. This variable was recorded along with key demographic data including age, gender, and body mass index (BMI). Other variables reviewed included mechanism of injury, Injury Severity Score (ISS), duration of hospital stay, in-hospital mortality, operative treatment, embolization, number of blood products transfused, and drop in hemoglobin over the first three admission days. Low-energy injuries included ground level falls. All other injuries were classified as high energy, which included motor vehicle collisions, motorcycle collisions, all-terrain vehicle collisions, bicycle collisions, falls from height, pedestrian versus auto, crush injuries, lawnmower/tractor collisions, and gunshot wound. Hemoglobin drop over the first three admission days (hemoglobin on admission minus hemoglobin nadir over first three days) was recorded and used as a surrogate for blood loss.
At our institution, the massive transfusion protocol is activated when class IV hemorrhagic shock is identified or when any trauma patient requires more than 4 units of packed red blood cells (PRBCs) during initial resuscitation. For those with massive transfusion protocol activation, initial resuscitation was guided as 1:1:1 (PRBC:fresh frozen plasma (FFP):platelets). Deactivation occurs once hemostasis is obtained, as determined by the attending trauma surgeon, then switching to TEG-based resuscitation as described in the trauma and acute care surgery literature [16–18]. TEG-based resuscitation was used for targeted treatment of coagulopathy in all trauma patients. FFP was given for a prolonged R-time (hypocoagulable state); cryoprecipitate was given for a prolonged K value (low fibrinogen levels); platelets were given for a decreased MA amplitude (decreased platelet activity); and either tranexamic acid (TXA) or aminocaproic acid were given as indicated for an elevated LY30 (excessive clot lysis). A summary of our institution’s TEG-based resuscitation is demonstrated in Table 1. In addition, local strategies for initial hemorrhage control in patients with major pelvic trauma include the use of temporary pelvic binders, peritoneal pelvic packing, Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA), pelvic external fixation, and/or angioembolization.
Table 1.
Institutional transfusion guide based on abnormal thromboelastography values
| Abnormal TEG value | Clinical cause | Transfuse |
|---|---|---|
| R time > 10 | ↓ Clotting factors | FFP ± RBCs |
| α-Angle < 53 | ↓ Fibrinogcn | Platelets ± cryoprecipitate ± RBCs |
| MA < 50 | ↓ Platelet function | Platelets ± RBCs |
| LY30 > 3% | Fibrinolysis | TXA ± RBCs |
R Reaction time, α alpha angle, MA maximal amplitude, LY30 clot lysis at 30 min, TEG thromboelastograph, FFP fresh frozen plasma, RBCs red blood cells, TXA tranexamic acid
The coagulation kinetics of traumatic pelvic fractures (pelvic ring and/or acetabulum) were investigated by analyzing the relationship between TEG on admission to mortality, blood loss, and blood product transfusion. Subgroup analysis was performed based on pelvic fracture type (isolated acetabulum, isolated pelvic ring, or combined acetabulum and pelvic ring). Continuous variables were reported using mean and standard deviation. Categorical variables were reported using ratios and percentages. Analysis of variance (ANOVA) and Student’s t- tests were used to compare continuous variables, while Chi-squared tests were used to compare differences in categorical variables. Statistical analysis was performed using JMP 11.0.0 (SAS Institute Inc., Cary, NC). A p value of < 0.05 was considered statistically significant.
Results
Of the 1,545 adult Full Trauma Team activations (FTTa) during the study period, 141 patients met the inclusion criteria. Mean age was 49.0 ± 20.8 years (range 18–100) with 67% male and 33% female. The mean injury severity score was 25.18 ± 12.8 (range 4–66). The injury mechanisms included 69 motor vehicle collisions, 15 motorcycle collisions, 11 all-terrain vehicle collisions, 3 bicycle collisions, 8 ground level falls, 12 falls from height, 14 pedestrian versus automobile, 2 crush injuries, 6 lawnmower/tractor collisions, and 1 gunshot wound. Average length of stay in the hospital was 14.1 ± 13.9 days (range 0–81 days).
The overall in-hospital mortality rate was 14.9%. A total of 65 patients (46.1%) underwent operative treatment (38 isolated pelvic ring injuries, 11 isolated acetabulum fractures, and 16 combined pelvic ring and acetabulum fractures). Operative treatment consisted of a variety of procedures including pelvic external fixation, percutaneous sacroiliac fixation, open reduction and internal fixation (ORIF) of the acetabulum, ORIF of the pubic symphysis, ORIF of the sacroiliac joint, ORIF of the iliac wings, lumbopelvic fixation, and one complex left total hip arthroplasty combined with ORIF of the acetabulum. Two patients underwent irrigation and debridement without hardware placement for open fractures. A total of 18 patients (12.7%) required embolization due to hemodynamic instability and/or blush present on computed tomography (CT) scan. Hemorrhage sources other than traumatic pelvic fracture included liver, spleen, and kidney lacerations, among other visceral injuries. Many patients also suffered additional upper and lower extremity fractures in addition to pelvic ring and/or acetabulum fractures.
Overall, red blood cell transfusion occurred in 78% of patients with a mean of 5.9 ± 10.2 PRBC transfusions per patient (range 0–87). A total of 1486 blood products were transfused with an average of 10.5 ± 23.3 blood products received per study patient (range 0–219). The total amounts transfused included 837 units of PRBCs, 465 units of FFP, 119 units of platelets, and 58 units of cryoprecipitate.
The mean percent lysis at 30 min on TEG (LY30) was 5.3% ± 16.1, which was significantly associated with mortality (p = 0.0002), PRBC transfusions (p < 0.0001), and total blood product transfusion (p < 0.0001). Average hemoglobin on admission was 12.4 ± 2.0 g/dL. The mean hemoglobin drop of 4.7 ± 2.2 g/dL (range 0–9.7) was significantly associated with LY30 (p < 0.0001). The association between ISS and LY30 was not significant (p = 0.11).
Table 2 provides an overview of patient demographics and treatment summary based on type of pelvic fracture. Of the 141 patients with traumatic pelvic fractures, there were 87 isolated pelvic ring fractures, 24 isolated acetabulum fractures, and 30 combined pelvic ring and acetabulum fractures. After stratifying based on pelvic fracture type, there were no significant differences noted in age (p = 0.313), gender (p = 0.292), or average length of hospital stay (p = 0.253). Similarly, no significant difference was noted between groups for in-hospital mortality (p = 0.898) or patients undergoing embolization (p = 0.832). The combined pelvic ring and acetabulum group had the greatest proportion of patients undergoing operative treatment (53.3%), but this was not significantly different from the isolated acetabulum (45.8%) or isolated pelvic ring (43.7%) groups (p = 0.658).
Table 2.
Comparison of demographic and clinical variables based on fracture type
| Total (n = 141) | Acelabulum (n = 24) | Pelvic ring (n = 87) | Combined (n = 30) | p value | |
|---|---|---|---|---|---|
| Age | 49.0 ± 20.8 | 43.5 ± 17.9 | 50.5 ± 21.0 | 46.8 ± 22.3 | 0.313 |
| Male (%) | 94/141 (66.7) | 19/24 (79.2) | 57/87 (65.5) | 18/30 (63.3) | 0.292 |
| High energy (%) | 133/141 (94.3) | 24/24 (100) | 81/87 (93.1) | 28/30 (93.3) | 0.214 |
| ISS | 25.2 ± 12.8 | 21.3 ± 11.7 | 25.7 ± 13.1 | 26.8 ± 12.5 | 0.253 |
| Length of stay (days) | 14.1 ± 13.9 | 12.5 ± 16.9 | 14.8 ± 14.3 | 13.3 ± 9.8 | 0.722 |
| Operative (%) | 65/141 (46.1) | 11/24 (45.8) | 38/87 (43.7) | 16/30 (53.3) | 0.658 |
| Embolization (%) | 18/141 (12.7) | 2/24 (8.3) | 11/87 (12.6) | 5/30 (16.7) | 0.832 |
| Mortality (%) | 21/141 (14.9) | 4/24 (16.7) | 12/87 (13.8) | 5/30 (16.7) | 0.898 |
| Mean RBCs | 5.9 ± 10.2 | 5.5 ± 8.8 | 6.4 ± 11.8 | 4.9 ± 5.1 | 0.783 |
| Mean blood products | 10.5 ± 23.3 | 9.4 ± 17.2 | 11.7 ± 27.8 | 8.2 ± 9.7 | 0.762 |
| Hemoglobin drop | 4.7 ± 2.2 | 4.6 ± 2.3 | 4.7 ± 2.2 | 4.8 ± 2.2 | 0.950 |
| LY30 | 5.3 ± 16.1 | 6.3 ± 18.6 | 5.3 ± 15.5 | 4.4 ± 16.3 | 0.918 |
ISS Injury Severity Score, RBCs red blood cells, LY30 clot lysis at 30 min
Mean PRBCs transfused for the isolated pelvic ring, isolated acetabulum, and combined groups were 6.4, 5.5, and 4.9 units, respectively (p = 0.783). The highest mean blood products were transfused in the pelvic ring group (11.7 units), but this was not significant compared to the other groups (p = 0.762). Similarly, no significant difference was noted between groups for hemoglobin drop over the first three admission days (p = 0.950). Mean LY30 for the isolated pelvic ring, isolated acetabulum, and combined groups were 5.3%, 6.3%, and 4.4%, respectively. There was no significant difference in LY30 among the subgroups (p = 0.918).
Discussion
The 14.9% rate of in-hospital mortality in this study is similar to previous studies reporting mortality rates of 14.5–23.9% for severely injured trauma patients [15, 19]. A recent study on TEG in acute pelvic fracture resuscitation found a similar mortality rate of 15% [20]. The high mortality rate of patients with traumatic pelvic fractures highlights the challenge of treating these complex injuries and controlling pelvis-associated hemorrhage.
Mamczak et al. conducted a recent study evaluating TEG-guided blood component resuscitation in trauma patients with acute pelvic and/or acetabulum fractures. In that study, 21 patients (52.5%) required operative treatment, and 6 patients (15.0%) required pelvic embolization [20]. These numbers are similar to our study, in which 65 patients (46.1%) underwent operative treatment, and 18 patients (12.7%) required embolization. The major finding of the Mamczak study was that using TEG-guided resuscitation resulted in an average transfusion ratio of 2.5:1:2.8 (PRBC:FFP:platelets). Although our institutional transfusion criteria is different from that reported in Mamczak et al., the average transfusion ratio in our study was 7.0:3.9:1 (PRBC:FFP:platelets). The Mamczak study also noted a trend toward higher total blood products transfused in the combined pelvic ring and acetabulum group (p = 0.08) when compared to the pelvic ring or acetabulum subgroups [20]. In our study, the isolated pelvic ring group had the highest mean total blood products transfused; however, this was not significant compared to the mean total blood products transfused in the isolated acetabulum or combined groups (p = 0.762).
The results of this study highlight the importance of fibrinolysis (LY30) and its relationship to blood loss and mortality in patients with traumatic pelvic fractures. Hyperfibrinolysis, as evidenced by an increased LY30 on TEG, was associated with increased blood loss and higher in-hospital mortality in this study. The higher rate of fibrin breakdown in these patients is likely attributed to ongoing hemorrhage and trauma-induced coagulopathy. Proposed mechanisms of this trauma-induced coagulopathy include consumption of clotting factors, dilution from fluids and blood products, hypothermia, and/or acidosis [21]. Interestingly, no relationship was found between the ISS and LY30.
Despite a profound upregulation in pro-coagulant mechanisms and increased thrombin-generating potential after traumatic injury, a proportion of patients suffering from traumatic pelvic injuries have an apparent decreased ability for coagulation [22–25]. Mechanisms responsible for this phenomenon are tissue hypoperfusion leading to increased fibrin breakdown driven by elevated activities of protein C molecules and platelet dysfunction [21, 26]. Hyperfibrinolytic states in trauma patients are likely related to excessive upregulation of profibrinolytic, tissue-derived plasminogen activator (tPA) molecules with an absent concomitant increase in antifibrinolytic plasminogen activator inhibitor (PAI) molecules [23]. These findings suggest that blood loss associated with traumatic pelvic injuries is due not only to mechanical disruption of vasculature, but also to an impaired ability to effectively regulate physiologic hemostasis.
The findings of this study suggest that limiting rates of fibrin breakdown may improve the patient’s innate ability to limit hemorrhage and subsequently improve outcomes. Lysine analogs, including tranexamic acid (TXA) and aminocaproic acid, act by inhibiting the conversion of plasminogen to plasmin and thereby prevent fibrin breakdown. Implementation of these medications in cases of traumatic pelvic injuries has proven beneficial in certain circumstances. The use of TXA to limit blood loss associated with traumatic pelvic fractures is consistent with recommendations from the CRASH-2 and MATTERs trials that recommend administration of TXA for bleeding trauma patients [14, 15, 19]. The CRASH-2 trial involving 20,211 trauma patients found that the timing of TXA administration was of utmost importance. TXA given earlier than 3 h from time of injury significantly reduced death due to bleeding (4.9% died in TXA group compared to 5.7% in placebo group; p = 0.0077). When given less than 3 h from injury, TXA also significantly reduced all-cause mortality at 28 days compared to placebo (14.5% in TXA group compared to 16.0% in placebo group; p = 0.0035). However, TXA given after 3 h from time of injury significantly increased death due to bleeding, as 4.4% died in the TXA group compared to the 3.1% of deaths in the placebo group (p = 0.004). The timing of TXA administration is critical, as the beneficial effects seem to diminish if administered beyond 3 h from trauma or injury [15].
This study, along with the CRASH-2 and MATTERs trials, highlights the importance of hyperfibrinolysis as a critical component in trauma-induced coagulopathy. TEG was first introduced in 1948 as a method to monitor coagulation kinetics; LY30 on TEG offers a rapid way to assess fibrinolysis [27, 28]. The standard TEG software, along with some institutions, use an LY30 of 7.5% or greater to represent hyperfibrinolysis. However, the results of this study demonstrated that an LY30 of 5.3% was significantly associated with blood loss and mortality. These results suggest that a lower LY30 threshold may be more appropriate to identify hyperfibrinolysis in patients with traumatic pelvic fractures. At our institution, any actively bleeding trauma patient in the acute phase of resuscitation is treated for an LY30 of 3% or greater; patients receive TXA if within 3 h of injury or aminocaproic acid if outside of 3 h. Recent studies have also shown that using an LY30 of 7.5% may be inappropriate and that the risk of death in trauma patients may rise at lower LY30 levels. A study by Chapman et al. found that an LY30 of 3% or greater was strongly predictive of an increased mortality risk and massive transfusion requirement in trauma patients with uncontrolled hemorrhage [29]. These findings support the early administration of either TXA or aminocaproic acid in severe trauma patients with uncontrolled hemorrhage and an LY30 of 3% or greater.
TEG is a useful tool for guiding resuscitation in the setting of trauma-induced coagulopathy. Mamczak et al. recently described the utility of TEG-guided transfusion in directing hemostatic resuscitation of patients with acute traumatic pelvic fractures. They noted a trend toward greater transfusion requirements in patients with combined pelvic ring and acetabular fractures compared to isolated pelvic ring or acetabular injury. However, they did not address the potential use of antifibrinolytics in response to an elevated LY30 [20]. The findings of this study recommend the routine use of TEG in the evaluation of traumatic pelvic fracture patients not only for the purpose of individualized transfusion guidance, but also for risk stratification and identification of patients at high risk for blood transfusion and death. Additionally, further studies should target specific LY30 thresholds at which TXA or aminocaproic acid would be most effective in limiting blood loss, transfusions, and mortality.
The findings of this study must be interpreted with knowledge of the limitations. First, the results are subject to the limitations of any retrospective study. For the majority of patients, TEG was only performed on admission and not repeated, which may have yielded valuable information on the effectiveness of correcting trauma-induced coagulopathy. Another limitation was that hemoglobin nadir was used as a surrogate to represent blood loss. A large proportion of the patients were multi-system traumas and suffered from additional associated injuries, making the precipitating cause of coagulopathy more complex. In addition, TEG data was for Full Trauma Team activation patients only, which imparts some degree of selection bias. The study did not include patients who were Partial Trauma Team activations, which makes it difficult to generalize the results. Patients who were transferred from outside hospitals or had delayed presentations were also included in this study. The importance of early treatment of hyperfibrinolysis in the trauma setting has been emphasized, especially with regard to TXA administration [14, 15]. The relationship of time from trauma and injury severity to hyperfibrinolysis is an area that can be more closely reviewed with well-designed prospective trials. Nonetheless, the present study supports the use of TEG for stratifying patients at increased risk of continued blood loss and mortality.
Conclusions
In conclusion, increasing fibrinolysis as indicated by an elevated LY30 on TEG in patients with traumatic pelvic fractures is associated with increased blood loss, blood product transfusions, and in-hospital mortality. Because of the significant association between elevated LY30 and poor outcomes, future studies should evaluate the clinical utility of reversing the hyperfibrinolysis exhibited on initial TEG.
Acknowledgements
The authors would like to acknowledge the contribution of Tyler E. Calkins, MD, to data collection and processing for this study.
Funding
No funding was received in support of this work.
Footnotes
Conflict of interest The authors report no conflicts of interest or competing interests.
Ethical approval Institutional Review Board approval was granted for this retrospective review.
Data availability
Reasonable requests will be considered.
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Associated Data
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Data Availability Statement
Reasonable requests will be considered.