We set out to determine the prevalence of acute traumatic coagulopathy among major trauma patients and was found to be 54%. This prevalence is much higher than what has been reported in other studies outside Uganda ranging from 24 to 34%
[6, 7, 10, 11]. This could be due to the fact that the design of this study included only patients with major trauma while some of other studies included all trauma patients (minor and major). The average time of injury to admission was 4 hours, compared to less than 70minutes in other contexts with well-functioning ambulance system and infrastructure
[7, 10] perhaps this time delay and other factors like hypothermia could have contributed to the high prevalence.
In addition, numerous authors have documented that cohorts of head injury patients have a high prevalence of coagulation abnormalities
[18–22]. The fact that some of the patients had head injuries certainly contributes to this picture of coagulopathy.
The mode of transport from the injury scene to hospital was inadequate or inappropriate, as most patients 155(90.7%) were brought by police patrol pick-up trucks and other cars which are not fitted with ambulance facilities hence didn’t get any pre hospital resuscitation, this is a common occurrence in most resource poor settings.
Pre hospitalization delay and length of hospital stay
The mean time from injury to arrival at hospital was 4 hours (with a range between 0.5 hours to 24 hours). For patient within Kampala (10-15km radius) it took 2 hours and those outside Kampala was 5 hours similar to findings from the other studies done in Kampala
The average time from injury to admission for coagulopathic patient was 4 hours and 3.6 hours for non coagulopathic patients (p=0.05), time of injury to admission could have contributed to the outcome in major trauma patients.
Duration of injury before admission is still high (therapeutic vacuum) as compared to other trauma centers
For coagulopathic group the mean LOS was more in the non coagulopathic group (p=0.001). Several investigators have reported significance increase in the LOS in trauma patients with coagulopathy
[6, 7, 10, 11].
However, the analysis for LOS in our study was done only for trauma patients who survived i.e. 144 (79%) patients. A considerable number of major trauma patients died within the first day 28 (15.4%) and second day 6 (3.3%) from admission with an overall mortality of 20.9%. Patients with coagulopathy who survived had longer LOS in either ICU or on the general wards as they needed more clinical management support.
Acute renal injury (ARI) and blood transfusion requirements
There were more ARI in the coagulopathic group 25 (25.3%) patients than in the non coagulopathic group 7 (8.4%) (p=0.003). This is comparable with other studies done outside Uganda on ATC
However the exact relationship between ARI and ATC needs to be further investigated.
There was no strong association between blood transfusion requirements and coagulopathy. A total of 41(41.4%) of patients with coagulopathy were transfused and 27 (32.5%) of patients without coagulopathy were transfused with different blood products (p=0.179). Increased transfusion requirements in major trauma patients were probably due to two events; blood loss at the scene (event) and continue loss secondary to coagulopathy.
Lack of significant difference in our study could be because of non compliance to standard protocol as far as blood transfusions practices is concerned in our setting because in part there is frequently inadequate supply of blood during the day but more so at night.
The overall mortality was 38(20.9%), this is higher mortality than what has been reported in developed world. Kirya reported a mortality of 39(26%) among major trauma patients in a study of outcome of major trauma patients at Mulago hospital 10 years ago
Other studies reported an overall mortality among major trauma patients ranging from 15% to 20%, however these studies where done in high resourced trauma centres
[6, 10, 11].
The mortality was more in the coagulopathic group 29(29.3%) than in the non coagulopathic group 9(12.2%) P=0.002, this is comparable with other studies
[6, 10, 11].
In this study, coagulopathy was a strong predictor of mortality in major trauma patients (IRR 2.7 95% CI 1.3 - 5.7, p = 0.001) and a predictor of morbidity (longer length of stay).
The Kaplan-Meier survival curves suggest a significant difference in probability of survival between patients with elevated PTT and those with normal (p=0.001). Most deaths resulting from elevated PTT occur early in the hospital stay, with the probability of survival paralleling between the two groups as time goes on. Thus PTT was a strong predictor of outcome than PT. Multiple regressions showed PTT, systolic BP, GCS were the variables that influenced outcome the most.
The ability to determine whether the trauma patient at admission is coagulopathic or not is a single most important predictor of outcome. This is comparable with other studies on ATC
[6, 7, 10]. This study was not without limitations; perhaps additional variables such as INR (International Normalized Ratio), temperature (to detect hypothermia), metabolic acidosis and fibrin break down products would have added valuable information to ascertain coagulopathy. So is the lack of blood products that is encountered often times in the late night hours we did not catergorise which patient came at night or during the day. With longer pre hospital times we may be seeing a mixture of trauma induced coagulopathy (TIC) and ATC rather than ATC alone. Regardless of whether ATC or TIC a large number of patients presented with deranged coagulation.