From the Division of Trauma (D.C., A.C., C.H.), Chandler Regional Medical Center, Chandler, Arizona; Section of Trauma Acute Care Surgery, Surgical Critical Care, and Burn Surgery (L.H.), Anschutz Medical Center, University of Colorado, Aurora, Colorado; Division of Critical Care & Acute Care Surgery (B.M.), University of Minnesota Health, Saint Paul, Minnesota; Division of Trauma Surgery & Surgical Critical Care (A.N.), Riverside University Health System Medical Center, Riverside, California; Department of Surgery (T.R.), Vanderbilt University Medical Center, Nashville, Tennessee; Program in Trauma ( R.T., T.S., D.S.), R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, Maryland.
J Trauma Acute Care Surg. 2021 Aug 1;91(2):331-335. doi: 10.1097/TA.0000000000003253.
As thromboelastography (TEG) becomes the standard of care in patients with hemorrhagic shock (HS), an association between concomitant traumatic brain injury (TBI) and coagulopathy by TEG parameters is not well understood and is thus investigated.
Retrospective analysis of trauma registry data at a single level 1 trauma center of 772 patients admitted with head Abbreviated Injury Scale (AIS) score of 3 and TEG studies between 2014 and 2017. Patients were stratified to moderate-severe TBI by head AIS scores of 3 and 4 (435 patients) and critical TBI by head AIS score of 5 (328 patients). Hemorrhagic shock was defined by base deficit of 4 or shock index of 0.9. Statistical analysis with unpaired t tests compared patients with critical TBI with patients with moderate-severe TBI, and patients were grouped by presence or absence of HS. A comparison of TBI data with conventional coagulation studies was also evaluated.
In the setting of HS, critical TBI versus moderate-severe TBI was associated with longer R time (p = 0.004), longer K time (p < 0.05), less acute angle (p = 0.001), and lower clot strength and stability (maximum amplitude [MA]) (p = 0.01). Worse TBI did not correlate with increased fibrinolysis by clot lysis measured by the percentage decrease in amplitude at 30 minutes after MA (p = 0.3). Prothrombin time and international normalized ratio failed to demonstrate more severe coagulopathy, while partial thromboplastin time was found to correlate with severity of TBI (p = 0.01). In patients with critical TBI, the presence of HS correlated with a statistically significant worsening of all parameters (p < 0.05) except for clot lysis measured by the percentage decrease in amplitude at 30 minutes after MA (LY-30).
Thromboelastography demonstrates that, with and without hemorrhagic shock, critical TBI correlates with a significant worsening of traumatic coagulopathy in comparison with moderate/severe TBI. In HS, critical TBI correlates with impaired clot initiation, impaired clot kinetics, and impaired platelet-associated clot strength and stability versus parameters found in moderate-severe TBI. Hemorrhagic shock correlates with worse traumatic coagulopathy in all evaluated patient groups with TBI. Conventional coagulation studies underestimate TBI-associated coagulopathy. Traumatic brain injury-associated coagulopathy is not associated with fibrinolysis.
Prognostic/epidemiological, level IV; prognostic/epidemiological, level III.
随着血栓弹力图（TEG）成为出血性休克（HS）患者的标准治疗方法，同时伴有创伤性脑损伤（TBI）和 TEG 参数凝血功能障碍的相关性尚不清楚，因此对此进行了研究。
对 2014 年至 2017 年间在一家一级创伤中心接受头部损伤严重程度评分（AIS）为 3 分且接受 TEG 研究的 772 例患者的创伤登记数据进行回顾性分析。患者根据头部 AIS 评分 3 分和 4 分（435 例患者）分为中重度 TBI，头部 AIS 评分 5 分（328 例患者）为严重 TBI。HS 定义为基础缺陷 4 或休克指数 0.9。采用配对 t 检验对严重 TBI患者与中重度 TBI 患者进行统计学分析，并根据是否存在 HS 对患者进行分组。还评估了 TBI 数据与常规凝血研究的比较。
在 HS 背景下，严重 TBI 与中重度 TBI 相比，R 时间更长（p = 0.004），K 时间更长（p < 0.05），急性角度更小（p = 0.001），凝块强度和稳定性降低（最大振幅[MA]）（p = 0.01）。严重程度增加的 TBI 与由 MA 后 30 分钟振幅降低百分比测量的纤维蛋白溶解（clot lysis）（p = 0.3）无相关性。凝血酶原时间和国际标准化比值未能显示出更严重的凝血功能障碍，而部分凝血活酶时间与 TBI 严重程度相关（p = 0.01）。在严重 TBI 患者中，HS 的存在与所有参数（p < 0.05）的统计学显著恶化相关，除了 MA 后 30 分钟振幅降低百分比测量的纤维蛋白溶解（LY-30）（p = 0.3）。
血栓弹力图显示，无论是否存在 HS，严重 TBI 与中度/重度 TBI 相比，创伤性凝血功能障碍明显恶化。在 HS 中，严重 TBI 与凝血起始受损、凝血动力学受损以及血小板相关凝块强度和稳定性受损相关，与中度/重度 TBI 相比。所有评估有 TBI 的患者组中，HS 与更严重的创伤性凝血功能障碍相关。常规凝血研究低估了与 TBI 相关的凝血功能障碍。与创伤性脑损伤相关的凝血功能障碍与纤维蛋白溶解无关。
预后/流行病学，IV 级；预后/流行病学，III 级。
