Division of General Surgery and Trauma, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.
J Trauma Acute Care Surg. 2012 Dec;73(6):1395-400. doi: 10.1097/TA.0b013e31825b9f05.
Acute traumatic coagulopathy (ATC) predicts poor outcome after injury. Females have been demonstrated to be hypercoagulable early in the posttrauma period. It remains unclear whether presence of ATC alters sex-based outcomes after injury. This study's objective was to characterize the sex dimorphism after severe injury in the presence and absence of ATC.
Data were obtained from a multicenter prospective cohort study of patients with blunt trauma and hemorrhagic shock. ATC was defined as arrival international normalized ratio (INR) of greater than 1.5. Cox regression was used to determine the independent risks of mortality and multiple-organ failure associated with sex in subjects with ATC and without (non-ATC) while controlling for important confounders. The sex mortality differences were characterized over time to determine at what point after injury any differential risks diverge.
Of 2,007 enrolled subjects, 1,877 had an arrival INR with 439 (23%) having ATC. There was no difference in incidence of ATC across sex (24% vs. 23%; p = 0.95). In the ATC group, no difference in Injury Severity Score, arrival INR, base deficit, temperature, or 24-hour blood requirements were found across sex. Cox hazard regression revealed that sex was not associated with mortality in non-ATC patients (hazard ratio, 0.94; 95% confidence interval, 0.6-1.5). Female sex was independently associated with mortality only in the ATC group (hazard ratio, 2.04; 95% confidence interval, 1.1-3.9; p = 0.03). These mortality risk differences across sex diverged within the first 24 hours after injury.
An exaggerated sex dimorphism exists for patients with ATC, with females demonstrating a twofold higher independent risk of mortality. These differential mortality risks across sex diverge early after injury, suggesting that they may be caused by an ongoing hemorrhage. Females who present with ATC at admission have a significantly greater risk of poor outcome. Further studies are warranted to explore the mechanisms responsible for sex dimorphism in the setting of ATC.
Prognostic study, level II.
急性创伤性凝血病（ATC）可预测创伤后不良预后。女性在创伤后早期表现出高凝状态。目前尚不清楚 ATC 的存在是否会改变创伤后的性别结局。本研究的目的是描述存在和不存在 ATC 时严重创伤后的性别差异。
数据来自一项多中心前瞻性队列研究，纳入了钝性创伤合并失血性休克的患者。ATC 的定义为到达时国际标准化比值（INR）大于 1.5。使用 Cox 回归确定存在 ATC 和不存在 ATC（非 ATC）的患者中，性别与死亡率和多器官衰竭相关的独立风险，同时控制重要的混杂因素。对性别死亡率差异进行时间特征分析，以确定在创伤后何时出现任何差异风险。
在纳入的 2007 名患者中，有 1877 名患者到达时的 INR 有记录，其中 439 名（23%）患有 ATC。性别之间 ATC 的发生率没有差异（24% vs. 23%；p = 0.95）。在 ATC 组中，性别之间的损伤严重程度评分、到达时 INR、基础不足、温度或 24 小时血液需求均无差异。Cox 风险回归显示，非 ATC 患者的性别与死亡率无关（危险比，0.94；95%置信区间，0.6-1.5）。只有在 ATC 组中，女性性别与死亡率独立相关（危险比，2.04；95%置信区间，1.1-3.9；p = 0.03）。这种性别间的死亡率风险差异在创伤后 24 小时内出现分歧。
对于患有 ATC 的患者，存在明显的性别二态性，女性的死亡率独立风险增加两倍。这种性别间的死亡率风险差异在创伤后早期出现，提示可能是由于持续出血引起的。入院时即存在 ATC 的女性患者的不良预后风险显著增加。需要进一步研究以探讨 ATC 情况下性别二态性的机制。
预后研究，II 级。
