In trauma patients hypothermia, acidosis and coagulopathy are known as the triad of death. Once established  they form a vicious circle that sends the patients spiralling towards death. An australian study looks at what happens to trauma mortality when patients have all three of them.

Coagulopathy, hypothermia and acidosis are markers of severe injury but also, independently of each other, predictors of poor outcome.

Working together they make up the ‘triad of death’ which creates a downward spiral where the three components amplify each other eventually killing the patient. Unless we intervene.

The study comes out of The Alfred Hospital in Melbourne. It is one of two major trauma centers in the state of Victoria, Australia. The authors went through ED records from a seven-year period. They identified the 90 patients who, on presentation to the ED, had the triad of death.

Hypothermia was defined as a temperature of less than 35 degrees. Coagulopathy was defined as an INR of more than 1,5. Acidosis was defined as a pH of less than 7.2, about where acidosis starts to negatively impact physiology.

Ninety patients had acidosis, hypothermia and coagulopathy at ED admission.

75,6% of them were males. Average age was 38,9 years. 91,1% of them suffered blunt injury. The average prehospital time from injury to ED presentation was  60,9 minutes.

Of these 90 patients there were 43 hospital deaths. Hospital mortality for patients presenting with the ‘triad of death’ was 47,8%.

Take home message
In this study, mortality for patients having the ´triad of death´ on presentation to the ED was almost fifty percent.

Interestingly, studies from nineties had similar mortality rates.   Since then there has been a lot of focus on hypothermia, coagulopathy and acidosis with active warming, blood products and factors, tromboelastography and what have you.

Despite those efforts the triad of death is still a killer.

Study lives here
Trauma patients with the ‘triad of death’. Mitra B, Tullio F, Cameron PA, Fitzgerald M. Emerg Med J. 2012 Aug;29(8):622-5. Epub 2011 Jul 23. PMID:21785151

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