东部创伤外科学会多中心试验：严重创伤性脑损伤患者的术前抗栓治疗使用和逆转策略比较。
Eastern Association for the Surgery of Trauma Multicenter Trial: Comparison of pre-injury antithrombotic use and reversal strategies among severe traumatic brain injury patients.
机构信息
From the Department of Surgery (B.K.Y., M.C., A.J.K.), University of Florida College of Medicine-Jacksonville, Jacksonville, Florida; Trauma Division (D.M.T.), Our Lady of the Lake RMC, Baton Rouge, Louisiana; Department of Surgery (S.T.), Tulane School of Medicine, New Orleans, Louisiana; Department of Surgery (T.J.S.), UC Health Memorial Hospital, Colorado Springs, Colorado; Department of Surgery (M.R.N., F.H.P.), Allegheny Health Network, Pittsburgh, Pennsylvania; Division of Trauma/Acute Care Surgery (N.B.), Tufts Medical Center, Boston, Massachusetts; Department of Surgery (K.M., M.B.), Loma Linda University Medical Center, Loma Linda, California; Department of Surgery (A.W.O.), Reading Hospital Tower Health, Reading, Pennsylvania; Department of Surgery (A.R.), Crozer Keystone Health System, Upland, Pennsylvania; Tulane University Medical School (K.D.N.), New Orleans, Louisiana; Department of Surgery (M.M.C.), Medical City Plano, Plano, Texas; Department of Surgery (J.M.H., K.L.L.), Via Christi Hospitals Wichita, Wichita, Kansas; Department of Surgery (L.L., R.B.), St. Mary's Medical Center, West Palm Beach, Florida; Department of Surgery (D.C.C.), Maine Medical Center, Portland, Maine; Department of Surgery (J.D.B., D.R.M.), Broward Health Medical Center, Fort Lauderdale, Florida; Department of Surgery (T.Z.H.), Indiana University School of Medicine, Eskenazi Health, Indianapolis, Indiana.
出版信息
J Trauma Acute Care Surg. 2022 Jan 1;92(1):88-92. doi: 10.1097/TA.0000000000003421.
BACKGROUND
Trauma teams are often faced with patients on antithrombotic (AT) drugs, which is challenging when bleeding occurs. We sought to compare the effects of different AT medications on head injury severity and hypothesized that AT reversal would not improve mortality in severe traumatic brain injury (TBI) patients.
METHODS
An Eastern Association for the Surgery of Trauma-sponsored prospective, multicentered, observational study of 15 trauma centers was performed. Patient demographics, injury burden, comorbidities, AT agents, and reversal attempts were collected. Outcomes of interest were head injury severity and in-hospital mortality.
RESULTS
Analysis was performed on 2,793 patients. The majority of patients were on aspirin (acetylsalicylic acid [ASA], 46.1%). Patients on a platelet chemoreceptor blocker (P2Y12) had the highest mean Injury Severity Score (9.1 ± 8.1). Patients taking P2Y12 inhibitors ± ASA, and ASA-warfarin had the highest head Abbreviated Injury Scale (AIS) mean (1.2 ± 1.6). On risk-adjusted analysis, warfarin-ASA was associated with a higher head AIS (odds ratio [OR], 2.43; 95% confidence interval [CI], 1.34-4.42) after controlling for Injury Severity Score, Charlson Comorbidity Index, initial Glasgow Coma Scale score, and initial systolic blood pressure. Among patients with severe TBI (head AIS score, ≥3) on antiplatelet therapy, reversal with desmopressin (DDAVP) and/or platelet transfusion did not improve survival (82.9% reversal vs. 90.4% none, p = 0.30). In severe TBI patients taking Xa inhibitors who received prothrombin complex concentrate, survival was not improved (84.6% reversal vs. 84.6% none, p = 0.68). With risk adjustment as described previously, mortality was not improved with reversal attempts (antiplatelet agents: OR 0.83; 85% CI, 0.12-5.9 [p = 0.85]; Xa inhibitors: OR, 0.76; 95% CI, 0.12-4.64; p = 0.77).
CONCLUSION
Reversal attempts appear to confer no mortality benefit in severe TBI patients on antiplatelet agents or Xa inhibitors. Combination therapy was associated with severity of head injury among patients taking preinjury AT therapy, with ASA-warfarin possessing the greatest risk.
LEVEL OF EVIDENCE
Prognostic, level II.
背景
创伤团队经常会遇到使用抗血栓（AT）药物的患者，当发生出血时，这极具挑战性。我们旨在比较不同 AT 药物对头部损伤严重程度的影响，并假设逆转 AT 药物不会改善严重创伤性脑损伤（TBI）患者的死亡率。
方法
这是一项由东部创伤外科学会赞助的前瞻性、多中心、观察性研究，共纳入了 15 个创伤中心。收集了患者的人口统计学数据、损伤负担、合并症、AT 药物以及逆转尝试等信息。主要观察指标为头部损伤严重程度和院内死亡率。
结果
对 2793 名患者进行了分析。大多数患者正在服用阿司匹林（乙酰水杨酸[ASA]，46.1%）。服用血小板化学受体阻滞剂（P2Y12）的患者平均损伤严重度评分（ISS）最高（9.1±8.1）。接受 P2Y12 抑制剂+ASA 和 ASA-华法林治疗的患者头部简明损伤评分（AIS）均值最高（1.2±1.6）。在风险调整分析中，在校正了 ISS、Charlson 合并症指数、初始格拉斯哥昏迷量表评分和初始收缩压后，华法林-ASA 与较高的头部 AIS 相关（优势比[OR]，2.43；95%置信区间[CI]，1.34-4.42）。在接受抗血小板治疗的严重 TBI（头部 AIS 评分≥3）患者中，使用去氨加压素（DDAVP）和/或血小板输注进行逆转并未改善生存（逆转率为 82.9%，未逆转率为 90.4%，p=0.30）。在接受凝血酶原复合物浓缩物治疗且服用 Xa 抑制剂的严重 TBI 患者中，生存并未得到改善（逆转率为 84.6%，未逆转率为 84.6%，p=0.68）。如前所述进行风险调整后，逆转尝试并未改善死亡率（抗血小板药物：OR 0.83；95%CI，0.12-5.9[ p=0.85]；Xa 抑制剂：OR，0.76；95%CI，0.12-4.64；p=0.77）。
结论
在接受抗血小板药物或 Xa 抑制剂治疗的严重 TBI 患者中，逆转尝试似乎不会带来死亡率获益。在接受损伤前 AT 治疗的患者中，联合治疗与头部损伤严重程度相关，其中 ASA-华法林风险最大。
证据等级
预后，II 级。
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