Battle Casualties in Korea: Studies of the Surgical Research Team, Volume IV

A Survey of the Hemostatic Mechanisms in Acute Post-traumaticRenal Insufficiency

Private First Class George L. Deaver, USA

(This information has been abstracted from a longer report preparedby Pfc Deaver.)

Hemorrhagic disease often appears in patients with severe renal insufficiencyof whatever etiology. In medical cases it may manifest itself only by theappearance of large bruises at points of venipuncture, but in the battlecasualty the disease is more serious because of the presence of wounds.

In December 1952 Captain Paul Teschan made a survey of the patientsat the Renal Insufficiency Center and reported the following manifestationsof hemorrhagic disease:

Patient 1-Gingival bleeding on the fourth post-wound day.

Patient 2-Tarry stools on post-wound days 9 to 15.

Patient 3-Bloody diarrhea on post-wound days 14 to 24.

Patient 4-Profuse bleeding from cut-downs and from wounds when dressingswere changed.

Patient 5-Bleeding from drains in the right upper quadrant on the thirteenthday. Laparotomy showed a generalized oozing from the bed of the right kidney.

Patient 6-Bloody vomitus, bloody diarrhea and bleeding through his incision.A laparotomy revealed generalized oozing from the traumatized areas.

Patient 7-Brisk bleeding from the wound on the eleventh day.

The tendency to bleed in these patients may sometimes threaten theirlives. It was for this reason that a study was undertaken to learn if possiblethe reason for this bleeding disease in battle casualties with post-traumaticrenal insufficiency.

Materials and Methods. The study was carried out in the firsthalf of the year 1953 at the Renal Insufficiency Center, 11th EvacuationHospital, operating in support of the U. S. Eighth Army at Wonju in Korea.The work was carried out under the supervision of Captain Paul E. Teschanand Major William A Meroney following a protocal that had been preparedby Lieutenant Russell Scott and Lieutenant Colonel William H. Crosby. Themethods for tests of the hemostatic system have been described by Scottand Crosby.¹ The

---

304

chemical procedures were performed in the laboratory of the Renal InsufficiencyCenter. The methods have been described elsewhere.² A batteryof tests was made serially in each case from the time the casualty wasadmitted to the Center until he died or was evacuated to Japan. Twenty-sevenpatients with severe renal insufficiency were included in the investigation.

Results. Table 1 shows the results of the battery of tests performedon several patients at times when marked abnormalities of one or more testswere evident. Table 2 shows the results of the serial testing done on asingle patient during the first 2 weeks of his convalescence. This demonstratesthe extent of the battery of tests and the interval at which the testswere performed in each of the subjects. An abstract of the results in allpatients follows.

Coagulation time determined in 27 patients was usually prolongedin those with hemorrhagic disease and the prolongation seemed proportionalto the severity of the disease. Patients with abdominal wounds seemed moreseverely affected than patients with wounds of the extremities but in generalthose with abdominal wounds were in a more critical condition than theothers.

Clot retraction was often grossly abnormal and when it occurredin a patient it usually remained abnormal for several days. This was observedin two patients with thrombocytopenia, but it also occurred where the plateletcount was adequate (Table 1, patient 102).

Platelet count (or an estimation of platelets made by examininga stained smear) demonstrated an adequate number in all patients exceptingthe two who had a temporary (5 or 6 days) but significant thrombocytopenia.

Tourniquet test for capillary fragility was abnormal in the twomen with thrombocytopenia. The test was not performed consistently in allpatients but it was usually negative when done. A few positive resultswere encountered in some patients during the time of hemorrhagic disease.

Fibrinogen levels were measured serially in 17 patients. Elevatedlevels were encountered almost invariably during the first 5 days afterwounding and in some cases persisted for as long as 39 days. Fibrinogenopeniawas not encountered.

Fibrinolytic activity was measured in 10 cases and the amountof lysis ranged from zero to 15 per cent, which values are not abnormal.In one patient only was there sufficient fibrinolytic activity to lysecompletely the whole-blood clot in 24 hours.

Plasma prothrombin activity as determined by the one-stage methodwas usually moderately reduced. It was never so low that it alone wouldhave caused abnormal bleeding.

---

305

Table 1. Hemostatic Tests in Acute Post-traumatic Renal Insufficiency

Patient	81			102		104
Site of Wound	Abdomen and Extremities			Extremities		Extremities
Day post-wound	6	11	12	23	26	17	23	27
Coagulation time (min.)	61	120s	120s	35	19	18	19	21
Clot retraction (1 hour)	poor	poor	complete	poor	poor	poor	complete	complete
Plasma prothrombin (% of normal)	25	35	50	70	95	95	73	95
Prothrombin consumption (% of plasma prothrombin)				0	90	65	95	95
Fibrinogen (mg./100 ml.)	610			439	556		572	590
Fibrinolysis		complete	complete					12
Bleeding time (min.)	4.5			35	2.5	1.5
Platelets	low		adeq.	low	140,000	adeq.	adeq.	adeq.
Tourniquet test	pos.	pos.	pos.	pos.	neg.		pos.	sl. pos.
Nonprotein nitrogen (mg./100 ml.)	390	282	348	285	193	216	247	188
Plasma sodium (mEq./L.)	135	151	146	139	148	134	170	149
Plasma potassium	6.3	6.0	6.1	4.3	3.8	6.1	5.1	5.2
Carbon dioxide (vol. %)		12.7		20	27	25	22	23
Plasma calcium (mg./100 ml.)				8.2	9.4	6.2		12.3
Plasma bilirubin (mg./100 ml.)	11.3	5.0	5.4	1.25	0.66		1.1	0.66
Urine output (ml./day)	1400			4085	2870	295	1570	2695

---

306

Table 2. Hemostatic Tests in Acute Post-traumatic Renal Insufficiency

Patient 102-Wounds of the Extremities.

Dialyzed on the Artificial Kidney on Post-wound Days 5,9 and 13.

Day post-wound	2	3	4	6	7	8	9	10	11	12	13	14
Coagulation time (min.)	23	29	15	40	22	18	19	15	16	16	16	16
Clot retraction (1 hour)	poor	poor	poor	poor	poor	poor	poor	poor	good	good	good	good
Plasma prothrombin (% of normal)	95	90		74	100	95	85	85	90	80		80
Prothrombin consumption (% of plasma prothrombin)	90	95	95	80	85	95		80	40	75	60	50
Fibrinogen (mg./100 ml.)	775
Bleeding time (min.)	3.5	3
Platelets	adeq	adeq	adeq	adeq	adeq	adeq	adeq	adeq	adeq	adeq	adeq	adeq
Tourniquet test	neg.	neg.
Hematocrit		40	34				37				28	27
Nonprotein nitrogen (mg./100 ml.)	64	121	189	114	132	182	265	153	200	212	292	116
Sodium (mEq./L.)	129	127	147	144	146	135	130	141	151	132	146	136
Potassium (mEq./L.)	6.7	7.4	6.7	5.5	7.1	7.0	7.5	5.9	6.1	6.4	7.8	3.6
Carbon dioxide (vol. %)	27	27	26	27.5		21.0	19	24	22.0	22	14	22.5
Calcium (mg./100 ml.)	7.7	8.4	8.7	7.0		8.0	7.2	6.7		6.3	6.0	11.0
Bilirubin (mg./100 ml.)	1.78	1.44	0.54	1.00	0.76	1.00	0.51	0.49	0.71	0.76		3.44
Urine output (ml./day)	385	135	50	85	150	105	135	85	140	195	240	100

---

307

Serum prothrombin activity (prothrombin consumption) was studiedin 13 patients. It was not often abnormal even when the coagulation timewas grossly prolonged. Prothrombin consumption was sometimes deficient,even in the presence of an adequate number of platelets (Table 1, patient104). When this was found in a patient it occurred consistently day afterday for several days.

Discussion. The battery of tests performed on patientswith acute post-traumatic renal insufficiency revealed no consistent singledefect that would account for their tendency to bleed. In some patientsthere was transient thrombocytopenia of a degree capable of causing thrombocytopenicpurpura. In others faulty clot retraction in the presence of adequate numbersof platelets suggested a qualitative deficiency in platelets. However,prothrombin consumption was not consistently decreased, suggesting thatthe platelets were not deficient in their ability to form thromboplastineven though the effect of clot retraction was diminished. The prolongationof clotting time remains unexplained. This was the most consistent abnormalityand it is one that deserves further study.

Notable in the over-all results in these many patients is the presenceof multiple small defects in the coagulation mechanism, differing in kindand degree from one patient to another. It is possible that the tendencyto bleed results from the summation of small defects none of which wouldby itself interfere with hemostasis.

Summary

1. Patients with severe renal insufficiency frequently develop an abnormaltendency to bleed. A battery of tests of the hemostatic system was performedserially on 27 battle casualties who had severe post-traumatic renal insufficiency.

2. There was no consistent fault found by these tests excepting prolongationof coagulation time and moderate deficiency of prothrombin activity. Mostof the patients showed other abnormalities but the time and degree werenot consistent.

3. The cause of the bleeding disease in severe renal insufficiency hasnot been identified.

References

1. Scott, R. Jr., and Crosby, W. H.: Changes In the CoagulationMechanism Following Wounding and Resuscitation with Stored Blood. A Studyof Battle Casualties in Korea. Blood 9: 609-621 (June), 1954. (Chapter8 in Volume II of this series.)

2. Meroney, W. H., and Herndon, R. F.: The Managementof Acute Renal Insufficiency. J. A. M. A. 155: 877-883 (July 3),1954. (Chapter 5 of this volume.)