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Coagulopathy in Pediatric Non-Accidental Trauma: Elevated INR on Admission Strongly Predicts Mortality in Victims of Abuse
Christine Leeper, MD, Isam Nasr, MD, Christine McKenna, MSN, CRNP and Barbara Gaines, MD, Children's Hospital of Pittsburgh of UPMC, Pittsburgh PA

Abstract:
Background: Victims of non-accidental trauma have poor outcomes compared to other injured patients. There is often a delay in diagnosis as these patients are commonly unable to communicate their situation to healthcare providers. These critically injured patients would benefit from early identification and therapy. Methods: We performed a retrospective review of our single hospital trauma registry from 2005-2014. We included all level 1 pediatric (age0-17) trauma patients who sustained non-accidental trauma according to ecode and had an INR drawn within two hours of arrival to the hospital. We excluded patients who had blood transfusion prior to arrival. We performed logistic regression modeling to control for admission hypotension, admission hypothermia, age, sex, ISS, and HeadAIS?3. Results: A total of 27.3% (n=22) of 93 patients studied were coagulopathic on admission. The overall mortality rate was 25.8% (n=24). All of the patients who died had an admission INR?1.5. Logistic regression analysis demonstrated that coagulopathy was a significant independent predictor of mortality; the odds of death for a coagulopathic patient were 9.75 times as high as for a non-coagulopathic patient after controlling for admission hypotension, admission hypothermia, age, sex, ISS, and HeadAIS?3 (p=0.002). Conclusions: Coagulopathy at the time of admission, as defined by INR>1.5, is both clinically relevant and has prognostic implications in children after non-accidental trauma. These patients should be targeted for aggressive interventions and monitoring with the goal of decreasing mortality and improving patient outcomes. Further study is warranted to investigate the effect of therapeutic interventions targeting coagulopathy.
Objective:
Explain the prognostic implications for the finding of coagulopathy on admission laboratory testing in level 1 pediatric trauma patients.
Objective Content: At the end of this activity the learner will be able to explain that level 1 pediatric trauma patients who have INR>1.5 on admission have significantly increased odds of mortality as compared to non-coagulopathic patients.


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