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coagulopathic group compared with the baseline group, al- assays use institution-specific cutoff values to determine TIC/
though the difference was not statistically significant. The mi- ATC. These assays probably provide a better determination
nor differences are likely attributable to the inclusion within of ATC and specific treatments needed. These Role 1 facilities
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the registries, which impute an inherent survivor bias. Our will be critical in large-scale combat operations when evacu-
findings suggest the need for vigilance in the detection of co- ation to a Role 2/3 becomes more tenuous. 67,68 Consequently,
agulopathy at Role 1 facilities. Better point-of-care diagnostic based on the aforementioned assays, further studies are needed
methods are needed as early identification of ATC can be po- to develop appropriate tools to detect and appraise ATC in
tentially reversed with products such as prothrombin complex these Role 1 facilities. Notably, the PHTR lacks granularity
55
and fibrinogen concentrates with stable shelf life. Addition- on many of the interventions, including volumes of crystal-
ally, the need to forward-stage blood products with a longer loid and colloid. Thus, it is an inherent limitation within the
shelf life are needed to correct coagulopathy in traumatically PHTR. 37
injured patients. 56–61
Conclusion
Consistent with civilian trauma literature, injury severity ap-
pears to be associated with the development of ATC in this Our study suggests that approximately one-third of wounded
patient population. 7,8,12 Extremity injuries appear to represent patients exhibit coagulopathy on presentation to a forward
a significant subset of injury patterns, which are consistent medical care facility. Our findings suggest that, in addition to
with prior military reports. However, in contrast to prior the use of shelf-stable blood products for management of ATC,
62
military literature, the largest proportion of our observed in- further studies are needed to ensure that advanced diagnostic
jury patterns resulted from blast injury. 1,63 In addition to injury tools and capabilities are available to facilitate early diagnosis
64
severity, massive transfusion has been associated with ATC. of ATC.
Wheeler et al. investigated wounding patterns associated with
massive transfusion and reported that the massive transfusion Acknowledgments
65
cohort had a median ISS of 25 (IQR 18–34). These are the The authors would like to thank the Joint Trauma System Data
two unique challenges associated with ATC, but may repre- Analysis Branch for their assistance with data acquisition.
sent a two-fold concern for those in the prehospital setting.
Identification of the risk of developing ATC and methods for Disclosures
identifying ATC will enable supply of potential products to re- The authors have no conflicts of interest to disclose.
verse ATC, as well as optimize massive transfusion practices. A
growing body of literature suggests that products with stable
shelf life such as prothrombin complex concentrate and fibrin- Funding
ogen concentrate may play a role in resuscitation after trauma No funding was received for this work.
induced hemorrhage. However, it is important to first iden-
55
tify the risk of ATC within this population to guide research, Disclaimer
development, and acquisitions. The views expressed in this article are those of the authors and
do not reflect the official policy or position of the U.S. Army
Limitations Medical Department, Department of the Army, Department of
As our data are observational only, we have limited ability to Defense, or the U.S. Government.
control confounding variables. Several variables may influ-
ence the observed data. Limited or incomplete documentation References
38
is common in the prehospital setting. By extension, the in- 1. Eastridge BJ, Costanzo G, Jenkins D, et al. Impact of joint the-
cluded data are possibly subject to entry error or incomplete ater trauma system initiatives on battlefield injury outcomes. Am J
Surg. 2009;198(6):852–857. doi:10.1016/j.amjsurg.2009.04.029
documentation. While measures have been taken to improve 2. Kotwal RS, Montgomery HR, Kotwal BM, et al. Eliminating pre-
prehospital military documentation, it is impossible to deter- ventable death on the battlefield. Arch Surg. 2011;146(12):1350–
mine incorrect data capture. 66 1358. doi:10.1001/archsurg.2011.213
3. Kotwal RS, Howard JT, Orman JA, et al. The effect of a golden hour
Attempts to detect and quantify ATC are inherently limited policy on the morbidity and mortality of combat casualties. JAMA
by factors associated with the degree of coagulopathy sever- Surg. 2016;151(1):15–24. doi:10.1001/jamasurg.2015.3104
ity based on traditional cascade assays when compared with 4. Mabry RL, Apodaca A, Penrod J, Orman JA, Gerhardt RT, Dorlac
WC. Impact of critical care-trained flight paramedics on casualty
studies utilizing thromboelastograms. 7,8,10–13 Laboratory tests survival during helicopter evacuation in the current war in Afghan-
such as INR or platelet counts were not designed for indica- istan. J Trauma Acute Care Surg. 2012;73(2 Suppl 1):S32–S37.
tions of coagulopathy in trauma; however, these represent the doi:10.1097/TA.0b013e3182606001
best available data within the deployed registries. The plate- 5. Howard JT, Kotwal RS, Stern CA, et al. Use of combat casualty care
let count does not determine their functionality. INR was data to sssess the US military trauma system during the Afghani-
designed to measure coagulation during clotting deficiencies stan and Iraq conflicts, 2001-2017. JAMA Surg. 2019;154(7):600–
608. doi:10.1001/jamasurg.2019.0151
and in patients undergoing anticoagulant treatments. Visco- 6. Howard JT, Kotwal RS, Santos-Lazada AR, Martin MJ, Stockinger
elastic assays of hemostasis including thromboelastometry ZT. Reexamination of a battlefield trauma golden hour policy.
(TEM) previously named rotational thromboelastography J Trauma Acute Care Surg. 2018;84(1):11–18. doi:10.1097/TA.
(ROTEG) or rotational thromboelastometry (ROTEM) and 0000000000001727.
thromboelastrography) represent the standard viscoelastic 7. Brohi K, Cohen MJ, Ganter MT, Matthay MA, Mackersie RC, Pit-
method for guided trauma resuscitation. Future iterations of tet JF. Acute traumatic coagulopathy: initiated by hypoperfusion:
the DoDTR should seek to include these additional laboratory modulated through the protein C pathway? Ann Surg. 2007;245(5):
812–818. doi:10.1097/01.sla.0000256862.79374.31
measurements. However, viscoelastic assays were not devel- 8. Brohi K, Singh J, Heron M, Coats T. Acute traumatic coagulopa-
oped to determine coagulopathy of trauma. The viscoelastic thy. J Trauma. 2003;54(6):1127-1130.

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