Epstein Daniel S, Mitra Biswadev, Cameron Peter A, Fitzgerald Mark, Rosenfeld Jeffrey V
Emergency and Trauma Centre, The Alfred Hospital, Commercial Road, Melbourne, VIC 3004, Australia; Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia.
Emergency and Trauma Centre, The Alfred Hospital, Commercial Road, Melbourne, VIC 3004, Australia; Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia; National Trauma Research Institute, Melbourne, VIC, Australia.
J Clin Neurosci. 2016 Jul;29:64-9. doi: 10.1016/j.jocn.2015.11.024. Epub 2016 Mar 2.
Acute traumatic coagulopathy (ATC) has been reported in the setting of isolated traumatic brain injury (iTBI) and is associated with poor outcomes. We aimed to evaluate the effectiveness of procoagulant agents administered to patients with ATC and iTBI during resuscitation, hypothesizing that timely normalization of coagulopathy may be associated with a decrease in mortality. A retrospective review of the Alfred Hospital trauma registry, Australia, was conducted and patients with iTBI (head Abbreviated Injury Score [AIS] ⩾3 and all other body AIS <3) and coagulopathy (international normalized ratio ⩾1.3) were selected for analysis. Data on procoagulant agents used (fresh frozen plasma, platelets, cryoprecipitate, prothrombin complex concentrates, tranexamic acid, vitamin K) were extracted. Among patients who had achieved normalization of INR or survived beyond 24hours and were not taking oral anticoagulants, the association of normalization of INR and death at hospital discharge was analyzed using multivariable logistic regression analysis. There were 157 patients with ATC of whom 68 (43.3%) received procoagulant products within 24hours of presentation. The median time to delivery of first products was 182.5 (interquartile range [IQR] 115-375) minutes, and following administration of coagulants, time to normalization of INR was 605 (IQR 274-1146) minutes. Normalization of INR was independently associated with significantly lower mortality (adjusted odds ratio 0.10; 95% confidence interval 0.03-0.38). Normalization of INR was associated with improved mortality in patients with ATC in the setting of iTBI. As there was a substantial time lag between delivery of products and eventual normalization of coagulation, specific management of coagulopathy should be implemented as early as possible.
急性创伤性凝血病（ATC）已在单纯性创伤性脑损伤（iTBI）患者中被报道，且与不良预后相关。我们旨在评估复苏期间给予ATC和iTBI患者促凝血药物的有效性，假设凝血障碍的及时纠正可能与死亡率降低相关。对澳大利亚阿尔弗雷德医院创伤登记处进行了回顾性研究，选取了iTBI（头部简明损伤评分[AIS]⩾3且所有其他部位AIS<3）和凝血病（国际标准化比值⩾1.3）患者进行分析。提取了所用促凝血药物（新鲜冰冻血浆、血小板、冷沉淀凝血因子、凝血酶原复合物浓缩剂、氨甲环酸、维生素K）的数据。在国际标准化比值已恢复正常或存活超过24小时且未服用口服抗凝剂的患者中，使用多变量逻辑回归分析来分析国际标准化比值正常化与出院时死亡之间的关联。共有157例ATC患者，其中68例（43.3%）在就诊后24小时内接受了促凝血产品治疗。首次产品给药的中位时间为182.5（四分位间距[IQR]115 - 375）分钟，给予凝血剂后，国际标准化比值恢复正常的时间为605（IQR 274 - 1146）分钟。国际标准化比值正常化与显著降低的死亡率独立相关（调整后的比值比为0.10；95%置信区间为0.03 - 0.38）。在iTBI背景下，ATC患者国际标准化比值正常化与死亡率改善相关。由于产品给药与凝血最终恢复正常之间存在相当长的时间间隔，应尽早实施凝血病的特异性管理。
