Clot Dynamics and Mortality : The MA-R Ratio

The coagulopathy of trauma, illustrated by a short R-time, is common and well understood. The physiology behind this may be early thrombin burst with rapid clot formation. Rapid consumption of fibrinogen, however, may result in weak clot and substrate depletion, resulting in low MA. While these characteristics are interesting, utilizing TEG to identify those at risk for subsequent bleeding diathesis, especially in those who do not demonstrate early signs of physiologic derangement, is challenging. We have developed a novel ratio utilizing TEG values to describe patients at specific risk for traumatic coagulopathy. The purpose of this study was to create a single TEG value which would reflect both the hypercoagulability, and hypocoagulability, of TIC. We hypothesized that this ratio, at admission, would be indicative of TIC and predictive of both blood product transfusion volumes and subsequent mortality. Patients admitted via the highest activation criteria at one of two Level 1 trauma centers were included if they received at least one unit of packed red blood cells (PRBC) in the first 24 hours of admission. The admission TEG was collected and a ratio was calculated by dividing the MA by the R-time (MAR). MAR quartiles were developed and multivariable logistic regression was utilized to determine odds of mortality. 330 patients with admission TEG were included. In all patients, median age was 35 years (IQR 25-54), ISS was 20 (IQR13-29), 76% were male and 43% suffered penetrating trauma. MAR groups were based on quartiles. Multivariable analysis, controlling for mechanism of injury, ISS and admission pH, showed that increasing ratios were associated with decreased odds of death. The lowest MAR ratios were also significantly associated with higher ISS, higher rates of blunt injury and higher plasma utilization without a significant difference in PRBC administration. Patients with the lowest MAR ratios demonstrated the highest mortality rates. This novel ratio may prove highly useful to predict at-risk patients early, when other physiologic indicators are absent. The mechanism driving this finding may rest in fibrinogen depletion resulting in weak clot. Patients with low MAR ratios may benefit from earlier resuscitation with cryoprecipitate, rather than the traditional use of plasma found in current massive transfusion protocols. III.