1. BLSA Trainee Prize Day
07 Aug 2012
Tapiwa Kundishora §, Peter Sherren§
Joseph Hussey*, Rabecca Martin*, Bruce Emerson*
Mike Parker~
§ST6/7 Anaesthesia
*Consultant Anaesthetist
~Statistician- Anglia Ruskin University
2. Introduction
Coagulopathy in trauma is multifactorial;
Hypothermia, acidosis, dilutional coagulopathy, pre-
existing bleeding diathesis, Disseminated
Intravascular Coagulation
Acute Traumatic Coagulopathy (ATC) demonstrated
by Brohi et al in 25 % of injured patients.
ATC is associated with a higher mortality.
Coagulopathy in burns patients also exists but is less
well understood
The presence of coagulopathy impacts in early burn
excision and grafting.
4. Aim
To determine the incidence of acute burn induced
coagulopathy (ABIC) in burns patients
To determine whether ABIC has any significance in
terms of patient outcomes
To determine if ABIC is an independent predictor of
mortality in burns patients
5. Methods
Retrospective review medical records -St Andrews
Burns and Plastics Centre Intensive Care Unit.
Inclusion Criteria
All patients admitted Jan 2006 to Dec 2011
Burns > 30 % Total Body Surface Area (TBSA)
6. Methods
Exclusion Criteria
admission ≥ 12 hours after the burn,
suspected cyanide poisoning
pre-existing bleeding diathesis or receipt of
anticoagulants
blood product administration
major non-thermal injuries
medical skin loss
Missing records
7. Definitions
Acute Burn Induced Coagulopathy (ABIC):
PT ≥14.6 s and/or APTT ≥ 45 s (local lab. reference &
Davenport et al) < 12 hours after thermal injury in
patients included in our study.
Abbreviated Burn Severity Index( ABSI)
age, sex, Total Burnt Surface Area (TBSA), full thickness
Burn, inhalational injury
8. ABSI
Age Sex Inhalational Full TBSA
Injury Thickness
0-20 1 Female 1 Yes 1 Yes 1 1-10 1
21-40 2 Male 0 No 0 No 2 11-20 2
41-60 3 21-30 3
61-80 4 31-40 4
81-100 5 41-50 5
51-60 6
61-70 7
71-80 8
81-90 9
91-100 10
9. Methods
Analysed for association between coagulopathy with
demographics, Abbreviated Burn Severity Index ( ABSI)
and fluid administration.
Non parametric data- median (IQR). Mann Whitney U and
Fisher’s exact tests
Logistic regression modelling to assess prognostic value of
a coagulopathy on the 28 day mortality rate.
Analysis of data was performed using Microsoft Excel 2010
(Microsoft, USA) and program R (R Foundation for
Statistical Computing, Austria) by a statistician.
A p value < 0.05 was considered statistically significant.
10. Results
total cases reviewed
(n=205)
excluded
(n=60)
missing data
(n=28)
Normal Clotting Acute Coagulopathy
(n=71) (n=46)
15. Results
Mortality rates in patients with normal coagulation and a
coagulopathy according to Abbreviated Burn Severity Index (ABSI).
16. Results
Scatter plot of Prothrombin time versus Abbreviated Burn Severity Index (ABSI).
Pearson product moment correlation coefficient r - 0.292 and p - 0.0013.
17. Results
Scatterplot of Prothrombin time versus serum lactate
Pearson product moment correlation coefficient r - 0.292 and p - 0.0013
18. Results
Predictive value of ABIC
Possible predictors of mortality assessed included
coagulopathy and all the components of the ABSI
(Age, sex, inhalational injury, full thickness burn and
TBSA).
The addition of an early coagulopathy to ABSI
improved the goodness of fit for the 28 day mortality
model from a R2 37.9% to 43.0% and a Scaled Brier
score 26.6% to 29.5% (p – 0.027).
As an independent predictor of 28 day mortality, ABIC
has an odds ratio (OR) of 3.42 (1.11-10.56).
19. Discussion
Various derangements of coagulation in major burns
patients has been described
Most of the published work focuses on DIC and a
delayed hypercoagulable state
The incidence of DIC is variable.
Barret et al 0.09 % incidence in 3331 patients
Lavrentieva et al 41/45 patients
Small number of patients overall in most( 5-60)
20. Discussion
ABIC was present in 39.3% of our patients. Brohi et al
showed an incidence of ATC of 25 %
ABIC was associated with severity and thickness of
burn (ABSI) & inhalational injury.
Acute Traumatic Coagulopathy is caused by
endothelial damage & hypoperfusion leading to
increased thrombomodulin expression
Similar mechanisms are likely to be involved in burns
patients
21. Conclusion
In patients with major thermal injuries, ABIC exists.
This coagulopathy correlates to serum lactate and ABSI but
is unrelated to fluid administration.
Mortality is higher in patients with ABIC
ABIC may be an independent predictor of
mortality, however a more robust study would be required
to prove this.
More research is required to evaluate clotting in burns
patients using methods other than PT/APTT like
thromboelastometry.
22. References
1. Brohi K, Singh J, Heron M, Coats T. Acute Traumatic coagulopathy. J Trauma. 2003;54:1127-1130.
2. Davenport R, Manson J, De’Arth H, Platton S, Coates A, Allard S, Hart D, Pearse RM, Pasi J, MacCullum
P, Stanworth S, Brohi K. Functional definition and characterization of acute traumatic coagulopathy. Crit Care
Med. 2011;39(12):2652-2658.
3. Maegele M, Lefering R, Yucei N, Tjardes T, Rixen D,Paffrath T, Simanski C, Neugebauer E, Bouillon B; AG
Polytrauma of the German Trauma Society (DGU). Early coagulopathy in multiple injury: an analysis from the
German Trauma Registry on 8724 patients. Injury. 2007 Mar;38(3):298-304.
4. Firth D, Davenport R, Brohi K. Acute traumatic coagulopathy. Curr Opin Anaesthesiol. 2012 Apr;25(2):229-34.
5. Schlag G, Redl H. Mediators in Trauma. Act Anesthesiol Belg. 1987;31:281-291.
6. Vindenes HA, Ulvestad E, Bjerknes R. Concentrations of cytokines in plasma of patients with large burns: their
relation to time after injury, burn size, inflammatory variables, infection, and outcome. Eur J Surg. 1988
Sep;164(9):647-56.
7. Latenser BA. Critical care of the burn patient: the first 48 hours. Crit Care Med. 2009 Oct;37(10):2819-26.
8. Lavrentieva A, Kontakiotis T, Bitzani M, Papaioannou-Gaki G, Parlapani A, Thomareis O, Tsotsolis N, Giala MA.
Early coagulation disorders after severe burn injury: impact on mortality. Intensive Care Medicine. 2008
Apr;34(4):700-6.
9. King DR, Namias N, Andrews DM. Coagulation abnormalities following thermal injury. Blood Coagul Fibrinolysis.
2010 Oct;21(7):666-9.
10. Kowal-Vern A, Gamelli RL, Walenga JM, Hoppensteadt D, Sharp-Pucci M, Schumacher HR. The effect of burn
wound size on hemostasis: a correlation of the hemostatic changes to the clinical state. J Trauma. 1992 Jul;33(1):50-
56; discussion 56-57.
11. Garcia-Avello A, Lorente JA, Cesar-Perez J, Garcia-Frade LJ, Alvardo R, Arevalo JM, Navarro JL, Esteban A. Degree
of hypercoagulability and hyperfibrinolysis is related to organ failure and prognosis after burn trauma. Thromb
Res. 1998 Jan;89(2):59-64.
12. Hendon DN. Total Burn Care. Vol 3. Saunders; 2003.
13. Roberts G, Lloyd M, Parker M, Martin R, Philip B,Shelley O, Dziewulski P. The Baux score is dead. Long live the
Baux score: 27 year retrospective cohort study of mortality at a regional burns service. J Trauma. 2012;72(1):251-256.
14. Tobiasen J, Hiebert JM, Edlich RF. The abbreviated burn severity index. Ann Emerg Med. 1982 May;11(5):260-2.
15. Barret JP, Gomez PA. Disseminated intravascular coagulation: a rare entity in burn injury. Burns. 2005
May;31(3):354-7.
16. Kowal-Vern A, Sharp-Pucci MM< Walenga JM, Dries GJ, Gamelli RL. Trauma and thermal injury: Comparison of
hemostatic and cytokine changes in the acute phase of injury. J Trauma. 1998 Feb;44(2):325-9.
