Norwood Scott H, Berne John D, Rowe Stephen A, Villarreal David H, Ledlie Jon T
Trauma Service, Department of Surgery, East Texas Medical Center, Tyler, Texas, USA.
J Trauma. 2008 Nov;65(5):1021-6; discussion 1026-7. doi: 10.1097/TA.0b013e31818a0e74.
To determine the safety of early enoxaparin for venous thromboembolism (VTE) prophylaxis in patients with blunt traumatic brain injury (TBI).
Prospective observational study of patients with TBI who received enoxaparin within 48 hours after admission. Brain computed tomography (CT) scans were obtained at the time of admission, at 24 hours, and at variable intervals thereafter based on clinical course. Patients were excluded from the study for intracerebral contusions >/=2 cm, multiple contusions within one brain region, subdural or epidural hematomas >/=8 mm, increased size or number of lesions on follow-up CT, persistent intracranial pressure >20 mm Hg, or neurosurgeon or trauma surgeon reluctance to initiate early pharmacologic VTE prophylaxis. Bleeding complications were defined as CT progression of hemorrhage by Marshall CT Classification or radiologists' report, regardless of any neurologic deterioration. Main outcomes measured were intracranial bleeding complications, discharge Glasgow Outcome Score, and hospital mortality.
Five hundred twenty-five patients were studied. Eighteen patients (3.4%) had progressive hemorrhagic CT changes after receiving enoxaparin, 12 of whom had no change in treatment, neurologic status, or outcome. Six patients (1.1%) had a change in treatment or potential outcome, including three who required subsequent craniotomy. Twenty-one patients (4.0%) died, and pharmacologic prophylaxis may have contributed to one death (0.2%). Discharge Glasgow Outcome Scores were 445 (84.8%) good recovery, 19 (3.6%) moderate disability, 36 (6.8%) severe disability, 4 (0.8%) persistent vegetative state, and 21 (4.0%) dead.
Enoxaparin should be considered as an option for early VTE prophylaxis in selected patients with blunt TBI. Early enoxaparin should be strongly considered in those patients with TBI with additional high risk traumatic injuries.
确定早期使用依诺肝素预防钝性颅脑损伤（TBI）患者静脉血栓栓塞症（VTE）的安全性。
对入院后48小时内接受依诺肝素治疗的TBI患者进行前瞻性观察研究。入院时、24小时时以及此后根据临床病程在不同时间间隔进行脑部计算机断层扫描（CT）。脑内挫伤≥2 cm、一个脑区内多发挫伤、硬膜下或硬膜外血肿≥8 mm、随访CT时病变大小或数量增加、持续颅内压>20 mmHg，或神经外科医生或创伤外科医生不愿启动早期药物性VTE预防的患者被排除在研究之外。出血并发症定义为根据Marshall CT分类或放射科医生报告的CT上出血进展，无论有无任何神经功能恶化。主要测量结果为颅内出血并发症、出院时格拉斯哥预后评分和医院死亡率。
共研究了525例患者。18例患者（3.4%）在接受依诺肝素治疗后出现CT上的进行性出血改变，其中12例患者的治疗、神经状态或预后无变化。6例患者（1.1%）的治疗或潜在预后发生变化，包括3例需要随后进行开颅手术的患者。21例患者（4.0%）死亡，药物预防可能导致1例死亡（0.2%）。出院时格拉斯哥预后评分显示，445例（84.8%）恢复良好，19例（3.6%）中度残疾，36例（6.8%）重度残疾，4例（0.8%）持续植物状态，21例（4.0%）死亡。
对于部分钝性TBI患者，应考虑将依诺肝素作为早期VTE预防的一种选择。对于伴有其他高风险创伤性损伤的TBI患者，应强烈考虑早期使用依诺肝素。
