Regular Article Application of the Japanese Association for Acute Medicine disseminated intravascular coagulation diagnostic criteria for patients at an early phase of trauma Atsushi Sawamura, Mineji Hayakawa, Satoshi Gando ⁎, Nobuhiko Kubota, Masahiro Sugano, Takeshi Wada, Ken-ichi Katabami Division of Acute and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Hokkaido University Graduate School of Medicine, N17W5, Kita-ku, Sapporo, 060-8638 Japan abstract article info Article history: Received 24 March 2009 Received in revised form 21 June 2009 Accepted 30 June 2009 Available online 3 August 2009 Keywords: disseminated intravascular coagulation (DIC) trauma diagnosis Japanese Association for Acute Medicine (JAAM) International Society on Thrombosis and Haemostasis (ISTH) Introduction: To validate the diagnostic criteria for disseminated intravascular coagulation (DIC) established by the Japanese Association for Acute Medicine (JAAM) at an early stage of trauma and to evaluate the hypothesis that the JAAM criteria can diagnose DIC with a higher sensitivity than the International Society on Thrombosis and Haemostasis (ISTH) overt DIC criteria. Materials and Methods: Based on a review of medical records, the data of 314 trauma patients were retrospectively obtained at 4 time points within 24 hr after arrival to the Emergency Department. Results: One hundred and forty-one JAAM DIC patients (44.9%) showed differences in the prevalence of massive bleeding and multiple organ dysfunction syndrome (MODS), and the outcome in comparison to the non-DIC patients. A stepwise logistic regression analysis showed that the maximum JAAM DIC scores independently predicted the patient death. All of the patients who developed ISTH overt DIC could be identified by the JAAM DIC criteria at early time points. The mortality rate and the incidence of massive bleeding and MODS of the patients with the ISTH overt DIC were higher than those only met the JAAM DIC criteria. Stepwise increases in the ISTH overt DIC scores and the incidence of the overt DIC were observed in accordance with the increases in the JAAM DIC scores. While the mortality rates were identical, there were marked differences in the incidence of MODS and Sequential Organ Failure Assessment scores between the DIC patients associated with trauma and sepsis. Conclusions: The results show that the JAAM scoring system has acceptable validity for the DIC diagnosis at an early phase of trauma, and also that the scoring system can diagnose DIC with a higher sensitivity than the criteria of the ISTH overt DIC. Bleeding as well as MODS may affect the prognosis of the patients associated with DIC. © 2009 Elsevier Ltd. All rights reserved. Trauma and sepsis are associated with disseminated intravascular coagulation (DIC) [1]. Although the activation of the tissue factor- dependent coagulation pathway at the top of the cascade is the same, DIC is subdivided into fibrinolytic (hemorrhagic) and antifibrinolytic (thrombotic) phenotypes [2,3]. In the fibrinolytic phenotype com- monly seen in hematopoietic malignancies, tissue-type plasminogen activator (t-PA)-induced fibrino/fibrinogenolysis and consumption coagulopathy lead to severe bleeding disorders [4]. On the other hand, DIC associated with sepsis, which is characterized by both insufficient anticoagulation control and inhibition of fibrinolysis by plasminogen activator inhibitor-1 (PAI-1), promotes microvascular thrombosis followed by multiple organ dysfunction syndrome (MODS) [1]. Hess et al. [5] pointed out that trauma patients are initially coagulopathic with increased bleeding, but soon change to a hypercoagulable state, which puts them at increased risk for thrombotic events. We can express this phenomenon in another way, namely, DIC with the fibrinolytic (hemorrhagic) phenotype at an early stage of trauma changes into DIC with the antifibrinolytic (thrombotic) phenotype at a later stage [6,7]. There is no difference in the pathogenesis of DIC between late-phase trauma and sepsis, however, fibrinogenolysis as well as fibrinolysis both play an important role in the bleeding in early stage trauma-related DIC. [1,6,7]. The subcommittee on DIC of the International Society on Thrombosis and Haemostasis (ISTH) and the Japanese Association for Acute Medicine (JAAM) DIC study group announced DIC diagnostic criteria [8,9]. Both criteria have been prospectively validated in a diverse population of patients admitted to the ICU, in which DIC diagnosed by the JAAM criteria was demonstrated to progress to the ISTH overt DIC [9–11]. The same result was obtained in a retrospective study that analyzed patients with sepsis [12]. The present study applied the JAAM DIC diagnostic criteria for patients at an early stage of trauma to test the hypotheses that the JAAM DIC scoring system has Thrombosis Research 124 (2009) 706–710 Abbreviations: APACHE II, Acute Physiology and Chronic Health Evaluation II; CI, confidence interval; DIC, disseminated intravascular coagulation; FDP, fibrin/fibrinogen degradation products; ISS, injury severity score; ISTH, International Society on Thrombosis and Haemostasis; JAAM, Japanese Association for Acute Medicine; MODS, multiple organ dysfunction syndrome; SIRS, systemic inflammatory response syn- drome; SOFA, Sequential Organ Failure Assessment. ⁎ Corresponding author. Tel.: +8111 706 7377; fax: +81 11 706 7378. E-mail address: gando@med.hokudai.ac.jp (S. Gando). 0049-3848/$ – see front matter © 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.thromres.2009.06.036 Contents lists available at ScienceDirect Thrombosis Research journal homepage: www.elsevier.com/locate/thromres