May A K, Young J S, Butler K, Bassam D, Brady W
Department of Surgery, University of Virginia Health Sciences Center, Charlottesville 22908, USA.
Am Surg. 1997 Mar;63(3):233-6; discussion 236-7.
Closed head injuries account for a significant portion of the morbidity and mortality following blunt trauma. Severe closed head injuries can be complicated by the development of a coagulopathy that may worsen blood loss and delay invasive neurosurgical procedures. Awaiting the results of coagulation studies prior to initiating treatment of such a coagulopathy introduces an inherent delay that may allow worsening of the coagulation disturbance and negatively influence outcome. This study was undertaken to see if a subgroup of patients with severe closed head injuries had a high probability of developing a coagulopathy and would warrant empiric treatment with fresh frozen plasma. The records of adult patients admitted to our trauma center with a Glasgow coma score (GCS) of < or = 8 and an extracranial abbreviated injury score of < or = 2 during a 9-month period were reviewed. Patients with penetrating trauma or whose altered level of consciousness was due to sedation or shock were excluded. The presence of coagulation abnormalities was determined according to prothrombin time and partial thromboplastin time obtained on admission. The time to invasive neurosurgical procedures for both coagulopathic and noncoagulopathic patients was determined as well as the mean number of hospital days, intensive care unit days, and the mortality for each group. Eighty-one per cent of the patients with a GCS < or = 6 were coagulopathic on admission, and all patients with a GCS of 3 or 4 were coagulopathic. In contrast, no patient with a score of 7 or 8 was coagulopathic. The coagulopathic patients tended to have a higher mortality than the noncoagulopathic patients (53 versus 22%) as well as longer intensive care unit and hospital stays. The mean time to neurosurgical intervention for the coagulopathic group was 226.0 +/- 190.9 minutes versus 84.8 +/- 38.4 minutes for the noncoagulopathic patients. We conclude that patients with closed head injuries who present with a GCS of 6 or less are candidates for empiric treatment for coagulopathy. Such treatment will negate the delay of awaiting coagulation studies. Whether or not such therapy shortens the interval between admission and neurosurgical procedures or alters outcome will require prospective study.
闭合性颅脑损伤在钝性创伤后的发病率和死亡率中占很大比例。严重的闭合性颅脑损伤可能并发凝血功能障碍，这可能会加重失血并延迟侵入性神经外科手术。在开始治疗这种凝血功能障碍之前等待凝血研究结果会带来固有的延迟，这可能会使凝血紊乱恶化并对结果产生负面影响。本研究旨在探讨是否有一部分严重闭合性颅脑损伤患者发生凝血功能障碍的可能性很高，是否需要经验性输注新鲜冰冻血浆进行治疗。回顾了在9个月期间入住我们创伤中心的格拉斯哥昏迷评分（GCS）≤8且颅外简明损伤评分≤2的成年患者的记录。排除穿透性创伤患者或意识改变是由镇静或休克引起的患者。根据入院时获得的凝血酶原时间和部分凝血活酶时间确定是否存在凝血异常。还确定了凝血功能障碍患者和非凝血功能障碍患者进行侵入性神经外科手术的时间，以及每组的平均住院天数、重症监护病房天数和死亡率。GCS≤6的患者中有81%入院时存在凝血功能障碍，所有GCS为3或4的患者均存在凝血功能障碍。相比之下，GCS评分为7或8的患者没有凝血功能障碍。凝血功能障碍患者的死亡率往往高于非凝血功能障碍患者（53%对22%），重症监护病房和住院时间也更长。凝血功能障碍组进行神经外科干预的平均时间为226.0±190.9分钟，而非凝血功能障碍患者为84.8±38.4分钟。我们得出结论，GCS≤6的闭合性颅脑损伤患者是经验性治疗凝血功能障碍的候选者。这种治疗将消除等待凝血研究结果的延迟。这种治疗是否能缩短入院与神经外科手术之间 的间隔或改变结果，还需要进行前瞻性研究。
