Score to predict traumatic coagulopathy

Acute traumatic coagulopathy (ATC) is present in up to 25% of major trauma patients by the time they arrive in hospital. A predictive tool called the coagulopathy of severe trauma (COAST) score was retrospectively derived and then prospectively validated in major trauma patients in the state of Victoria, Australia. The definition of ATC was INR > 1.5 (1.0–1.3) or aPTT of > 60 s (25–38 s) on hospital presentation.

The study claims that a subgroup of patients with acute traumatic coagulopathy can be accurately identified based on simple observations in the pre-hospital phase or immediately on presentation to the ED, and that this could improve the feasibility of prospective interventional studies. Perhaps this will lead on to evaluation of pre-hospital tranexamic acid or even blood products?

At the cutoff score of ≥3, 40 coagulopathic patients would have been missed with 60 patients correctly predicted. The authors argue that while the low sensitivity of the score missed these coagulopathic patients, they had significantly better outcomes (and contained a significantly higher proportion of patients with isolated severe head injury).

Introduction: The inability to accurately predict acute traumatic coagulopathy (ATC) has been a key factor in the low level of evidence guiding its management. The aim of this study was to develop a tool to accurately identify patients with ATC using pre-hospital variables without the use of pathology or radiological testing.

Methods: Retrospective data from the trauma registry on major trauma patients were used to identify vari- ables independently associated with coagulopathy. These variables were clinically evaluated to develop a scoring system to predict ATC, which was prospectively validated in the same setting.

Results: There were 1680 major trauma patients in the derivation dataset, with 151 patients being coagulopathic. Pre-hospital variables independently associated with ATC were entrapment (OR 1.85; 95% CI: 1.12–3.06), temperature (OR 0.60; 95% CI: 0.60–0.72), systolic blood pressure (OR 0.99; 95% CI: 0.98–0.99), abdominal or pelvic content injury (OR 2.0; 95% CI: 1.27–3.12) and pre-hospital chest decompression (OR 4.99; 2.77–8.99). The COAST score was developed, scoring points for entrapment, temperature <35 ◦ C, systolic blood pressure <100 mm Hg, abdominal or pelvic content injury and chest decompression. Prospectively validated using 1225 major trauma patients, a COAST score of ≥3 had a specificity of 96.4% with a sensitivity of 60.0%, with an area under the receiver operating characteristic curve of 0.83 (0.78–0.88).

Conclusions: The COAST score accurately identified a group of patients with ATC using pre-hospital obser- vations. This predictive tool can be used to select patients for inclusion into prospective studies examining management options for ATC. Mortality in these patients is high, potentially improving feasibility of outcome studies.