Clinical pathology selected abstracts

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Editor: Deborah Sesok-Pizzini, MD, MBA, professor, Department of Clinical Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, and chief, Division of Transfusion Medicine, Children’s Hospital of Philadelphia.

Trauma resuscitation considerations: gender as a biological variable

April 2019—Sex dimorphisms in coagulation are well established, with females manifesting a more hypercoagulable profile, but the relationship between sex dimorphism in coagulation and trauma outcomes has not been investigated. Trauma-induced hemorrhage remains a leading cause of early post-injury death. While several studies have reported decreased morbidity and mortality among females following trauma, other studies found increased mortality or no gender-related differences. None of these studies have accounted for the whole blood hemostatic state. The authors conducted this study to determine the differences between males and females following trauma and to examine how differences in gender-specific coagulation affect clinical outcomes, specifically massive transfusion and death. The authors hypothesized that severely injured females are more hypercoagulable and, therefore, have lower rates of massive transfusion and mortality. They prospectively examined the hemostatic profiles, using thrombelastography (TEG), and clinical outcomes from all trauma activation patients from two level one trauma centers, with gender as an experimental variable. The authors compared coagulation profiles between genders and examined their association with massive transfusion and mortality. Of the 464 patients, 23 percent were female. By TEG, the female patients had a more hypercoagulable profile, with a higher angle (clot propagation) and maximum amplitude (clot strength). In addition, the females were less likely than the males to present with hyperfibrinolysis or prolonged activating clotting time. Furthermore, female gender was a survival benefit in the setting of depressed clot strength, and hyperfibrinolysis was associated with a higher case-fatality rate in males. The authors concluded that severely injured females have a more hypercoagulable profile than males and this protects against mortality in the setting of trauma-induced coagulopathy. They noted that this may challenge the clinical bias of a unified transfusion strategy and suggest that females require less blood product transfusion and are less likely to require antifibrinolytics. This study further highlights the need to investigate gender as a biological variable in trauma populations.

Coleman JR, Moore EE, Samuels JM, et al. Trauma resuscitation considerations: sex matters. J Am Coll Surg. 2019. doi:10.1016/j.jamcollsurg.​2019.01.009.

Correspondence: Dr. Erik D. Peltz at erik.peltz@ucdenver.edu