Liras Ioannis N, Caplan Henry W, Stensballe Jakob, Wade Charles E, Cox Charles S, Cotton Bryan A
Department of Surgery, McGovern Medical School, Houston, TX.
Section for Transfusion Medicine, Capital Region Blood Bank, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark; Department of Anesthesia, Centre of Head and Orthopedics, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.
J Am Coll Surg. 2017 Apr;224(4):625-632. doi: 10.1016/j.jamcollsurg.2016.12.046. Epub 2017 Jan 25.
Acute coagulopathy of trauma in children is of potential importance to clinical outcomes, but knowledge is limited and has only been investigated using conventional coagulation testing. The purpose of this study was to assess the prevalence and impact of arrival coagulopathy, determined by viscoelastic hemostatic testing, in severely injured children.
Pediatric patients (younger than 17 years of age) who were admitted January 2010 to May 2016 and met highest-level trauma activation were included. Patients were divided into 2 groups (coagulopathy and controls) based on arrival rapid thrombelastography values. Coagulopathy was defined as the presence of any of the following on rapid thrombelastography: activated clotting time ≥128 seconds, α-angle ≤65 degrees, maximum amplitude ≤55 mm, and lysis at 30 minutes from 20-mm amplitude ≥3%. Logistic regression was used to adjust for age, sex, blood pressure, mechanism, and injury severity.
Nine hundred and fifty-six patients met inclusion; 507 (57%) were coagulopathic and 449 (43%) were not (noncoagulopathic and control cohort). Coagulopathic patients were younger (median 14 vs 15 years) and more likely to be male (68% vs 60%) and Hispanic (38% vs 31%) (all p < 0.05). Coagulopathic patients received more RBC and plasma transfusions and had fewer ICU and ventilator-free days and higher mortality (12% vs 3%; all p < 0.05). Of these 956, 197 (21%) sustained severe brain injury-123 (62%) were coagulopathic and 74 (38%) were noncoagulopathic. The mortality difference was even greater for coagulopathic head injuries (31% vs 10%; p = 0.002). Adjusting for confounders, admission coagulopathy was an independent predictor of death, with an odds ratio of 3.67 (95% CI 1.768 to 7.632; p < 0.001).
Almost 60% of severely injured children and adolescents arrive with evidence of acute traumatic coagulopathy. The presence of admission coagulopathy is associated with high mortality in children, especially among those with head injuries.
儿童创伤性急性凝血病对临床结局具有潜在重要性，但相关知识有限，且仅通过传统凝血检测进行过研究。本研究旨在评估通过黏弹性止血检测确定的入院时凝血病在重伤儿童中的患病率及影响。
纳入2010年1月至2016年5月入院且符合最高级别创伤激活标准的17岁以下儿科患者。根据入院时快速血栓弹力图值将患者分为两组（凝血病组和对照组）。凝血病定义为快速血栓弹力图出现以下任何一项：活化凝血时间≥128秒、α角≤65度、最大振幅≤55毫米以及20毫米振幅30分钟时的溶解率≥3%。采用逻辑回归对年龄、性别、血压、受伤机制和损伤严重程度进行校正。
956例患者符合纳入标准；507例（57%）存在凝血病，449例（43%）无凝血病（非凝血病组和对照组）。凝血病患者年龄更小（中位数14岁对15岁），更可能为男性（68%对60%）和西班牙裔（38%对31%）（均p<0.05）。凝血病患者接受更多的红细胞和血浆输注，无ICU治疗和无呼吸机天数更少，死亡率更高（12%对3%；均p<0.05）。在这956例患者中，197例（21%）遭受严重脑损伤，其中123例（62%）存在凝血病，74例（38%）无凝血病。凝血病性头部损伤的死亡率差异更大（31%对10%；p=0.002）。校正混杂因素后，入院时凝血病是死亡的独立预测因素，比值比为3.67（95%CI 1.768至7.632；p<0.001）。
近60%的重伤儿童和青少年入院时存在急性创伤性凝血病证据。入院时凝血病与儿童高死亡率相关，尤其是头部受伤的儿童。
