Acute and delayed mild coagulopathy are related to outcome in patients with isolated traumatic brain injury

Sjoerd Greuters, Annelies van den Berg, Gaby Franschman, Victor A Viersen, Albertus Beishuizen, Saskia M Peerdeman, Christa Boer, ALARM-BLEEDING investigators, Sjoerd Greuters, Annelies van den Berg, Gaby Franschman, Victor A Viersen, Albertus Beishuizen, Saskia M Peerdeman, Christa Boer, ALARM-BLEEDING investigators

Abstract

Introduction: The relationship between isolated traumatic brain injury (TBI) associated coagulopathy and patient prognosis frequently lacks information regarding the time course of coagulation disorders throughout the post-traumatic period. This study was conducted to assess the prevalence and time course of post-traumatic coagulopathy in patients with isolated TBI and the relationship of these hemostatic disorders with outcome.

Methods: The local Human Subjects Committee approved the study. We retrospectively studied the medical records of computed tomography (CT)-confirmed isolated TBI patients with an extracranial abbreviated injury scale (AIS) <3 who were primarily referred to a Level 1 trauma centre in Amsterdam (n = 107). Hemostatic parameters including activated partial thromboplastin time (aPTT), prothrombin time (PT), platelet count, hemoglobin, hematocrit, glucose, pH and lactate levels were recorded throughout a 72-hour period as part of a routine standardized follow-up of TBI. Coagulopathy was defined as a aPPT >40 seconds and/or a PTT in International Normalized Ratio (INR) >1.2 and/or a platelet count <120*109/l.

Results: Patients were mostly male, aged 48 ± 20 years with a median injury severity score of 25 (range 20 to 25). Early coagulopathy as diagnosed in the emergency department (ED) occurred in 24% of all patients. The occurrence of TBI-related coagulopathy increased to 54% in the first 24 hours post-trauma. In addition to an increased age and disturbed pupillary reflex, both coagulopathy upon ED arrival and during the first 24 hours post-trauma provided an independent prognostic factor for unfavorable outcome (odds ratio (OR) 3.75 (95% CI 1.07 to 12.51; P = 0.04) and OR 11.61 (2.79 to 48.34); P = 0.003).

Conclusions: Our study confirms a high prevalence of early and delayed coagulopathy in patients with isolated TBI, which is strongly associated with an unfavorable outcome. These data support close monitoring of hemostasis after TBI and indicate that correction of coagulation disturbances might need to be considered.

Figures

Figure 1
Figure 1
The relative number of patients with a diagnosis of coagulopathy. The relative number of patients with a diagnosis of coagulopathy upon emergency department arrival and at 6, 24 and 48 hours post-trauma.

References

    1. Olson JD, Kaufman HH, Moake J, O'Gorman TW, Hoots K, Wagner K, Brown CK, Gildenberg PL. The incidence and significance of hemostatic abnormalities in patients with head injuries. Neurosurgery. 1989;24:825–832. doi: 10.1227/00006123-198906000-00007.
    1. Van der Sande JJ, Veltkamp JJ, Boekhout-Mussert RJ, Bouwhuis-Hoogerwerf ML. Head injury and coagulation disorders. J Neurosurg. 1978;49:357–365. doi: 10.3171/jns.1978.49.3.0357.
    1. Goodnight SH, Kenoyer G, Rapaport SI, Patch MJ, Lee JA, Kurze T. Defibrination after brain-tissue destruction: A serious complication of head injury. N Engl J Med. 1974;290:1043–1047. doi: 10.1056/NEJM197405092901903.
    1. Drake TA, Morrissey JH, Edgington TS. Selective cellular expression of tissue factor in human tissues. Implications for disorders of hemostasis and thrombosis. Am J Pathol. 1989;134:1087–1097.
    1. Cohen MJ, Brohi K, Ganter MT, Manley GT, Mackersie RC, Pittet JF. Early coagulopathy after traumatic brain injury: the role of hypoperfusion and the protein C pathway. J.Trauma. 2007;63:1254–1261. doi: 10.1097/TA.0b013e318156ee4c.
    1. Morel N, Morel O, Petit L, Hugel B, Cochard JF, Freyssinet JM, Sztark F, Dabadie P. Generation of procoagulant microparticles in cerebrospinal fluid and peripheral blood after traumatic brain injury. Trauma. 2008;64:698–704. doi: 10.1097/TA.0b013e31816493ad.
    1. Brohi K, Cohen MJ, Ganter MT, Schultz MJ, Levi M, Mackersie RC, Pittet JF. Acute coagulopathy of trauma: hypoperfusion induces systemic anticoagulation and hyperfibrinolysis. J Trauma. 2008;64:1211–1217. doi: 10.1097/TA.0b013e318169cd3c.
    1. Gando S, Tedo I, Kubota M. Posttrauma coagulation and fibrinolysis. Crit Care Med. 1992;20:594–600. doi: 10.1097/00003246-199205000-00009.
    1. Harhangi BS, Kompanje EJ, Leebeek FW, Maas AL. Coagulation disorders after traumatic brain injury. Acta Neurochir (Wien) 2008;150:165–175. doi: 10.1007/s00701-007-1475-8.
    1. Stein S, Young G, Talucci R, Greenbaum B, Ross S. Delayed Brain Injury after Head Trauma: Significance of Coagulopathy. Neurosurgery. 1992;30:160–165. doi: 10.1227/00006123-199202000-00002.
    1. Wafaisade A, Lefering R, Tjardes T, Wutzler S, Simanski C, Paffrath T, Fischer P, Bouillon B, Maegele M. Trauma Registry of DGU. Acute Coagulopathy in Isolated Blunt Traumatic Brain Injury. Neurocrit Care. 2010;12:211–219. doi: 10.1007/s12028-009-9281-1.
    1. Carrick MM, Tyroch AH, Youens CA, Handley T. Subsequent development of thrombocytopenia and coagulopathy in moderate and severe head injury: support for serial laboratory examination. J Trauma. 2005;58:725–729. doi: 10.1097/01.TA.0000159249.68363.78.
    1. Zehtabchi S, Soghoian S, Liu Y, Carmody K, Shah L, Whittaker B, Sinert R. The association of coagulopathy and traumatic brain injury in patients with isolated head injury. Resuscitation. 2008;76:52–56. doi: 10.1016/j.resuscitation.2007.06.024.
    1. Talving P, Benfield R, Hadjizacharia P, Inaba K, Chan LS, Demetriades D. Coagulopathy in severe traumatic brain injury: a prospective study. J Trauma. 2009;66:55–61. doi: 10.1097/TA.0b013e318190c3c0.
    1. Franschman G, Peerdeman SM, Andriessen TM, Greuters S, Toor EJ, Vos PE, Bakker FC, Loer SA, Boer C. Influence of secondary prehospital risk factors on outcome of patients with severe traumatic brain injury. Resuscitation. 2010. in press .
    1. MRC CRASH Trial Collaborators. Perel P, Arango M, Clayton T, Edwards P, Komolafe E, Poccock S, Roberts I, Shakur H, Steyerberg E, Yutthakasemsunt S. Predicting outcome after traumatic brain injury: practical prognostic models based on large cohort of international patients. BMJ. 2008;336:425–429. doi: 10.1136/bmj.39461.643438.25.
    1. Stein SC, Chen XH, Sinson GP, Smith DH. Intravascular coagulation: a major secondary insult in nonfatal traumatic brain injury. J Neurosurg. 2002;97:1373–1377. doi: 10.3171/jns.2002.97.6.1373.
    1. Hulka F, Mullins RJ, Frank EH. Blunt brain injury activates the coagulation process. Arch Surg. 1996;131:923–927.
    1. Cosgriff N, Moore EE, Sauaia A, Kenny-Moynihan M, Burch JM, Galloway B. Predicting life-threatening coagulopathy in the massively transfused trauma patient: hypothermia and acidosis revisited. J Trauma. 1997;42:857–861. doi: 10.1097/00005373-199705000-00016.
    1. Jeremitsky E, Omert L, Dunham CM, Protetch J, Rodriguez A. Harbingers of poor outcome the day after severe brain injury: hypothermia hypoxia and hypoperfusion. J Trauma. 2003;54:312–319. doi: 10.1097/01.TA.0000037876.37236.D6.
    1. Engstrom M, Schott U, Nordstrom CH, Romner B, Reinstrup P. Increased lactate levels impair the coagulation system--a potential contributing factor to progressive hemorrhage after traumatic brain injury. J Neurosurg Anesthesiol. 2006;18:200–204. doi: 10.1097/01.ana.0000211002.63774.8a.
    1. Taylor FB Jr, Toh CH, Hoots WK, Wada H, Levi M. Towards definition, clinical and laboratory criteria, and a scoring system for disseminated intravascular coaguloation. Thromb Haemost. 2001;86:1327–1330.
    1. Saggar V, Mittal RS, Vyas MC. Hemostatic abnormalities in patients with closed head injuries and their role in predicting early mortality. J.Neurotrauma. 2009;26:1665–1668. doi: 10.1089/neu.2008.0799.
    1. Halpern CH, Reilly PM, Turtz AR, Stein SC. Traumatic coagulopathy: the effect of brain injury. J Neurotrauma. 2008;25:997–1001. doi: 10.1089/neu.2008.0548.
    1. Brohi K, Singh J, Heron M, Coats T. Acute traumatic coagulopathy. J.Trauma. 2003;54:1127–1130. doi: 10.1097/01.TA.0000069184.82147.06.
    1. Cortiana M, Zagara G, Fava S, Seveso M. Coagulation abnormalities in patients with head injury. J Neurosurg Sci. 1986;30:133–138.
    1. Maegele M, Lefering R, Yucel N, Tjardes T, Rixen D, Paffrath T, Simanski C, Neugebauer E, Bouillon B. AG Polytrauma of the German Trauma Society (DGU) Early coagulopathy in multiple injury: an analysis from the German Trauma Registry on 8724 patients. Injury. 2007;38:298–304. doi: 10.1016/j.injury.2006.10.003.
    1. Sloan EP, Zalenski RJ, Smith RF, Sheaff CM, Chen EH, Keys NI, Crescenzo M, Barrett JA, Berman E. Toxicology screening in urban trauma patients: drug prevalence and its relationship to trauma severity and management. J Trauma. 1989;29:1647–1653. doi: 10.1097/00005373-198912000-00011.
    1. Etemadrezaie H, Baharvahdat H, Shariati Z, Lari SM, Shakeri MT, Ganjeifar B. The effect of fresh frozen plasma in severe closed head injury. Clin Neurol Neurosurg. 2007;109:166–171. doi: 10.1016/j.clineuro.2006.09.001.
    1. McQuay N Jr, Cipolla J, Franges EZ, Thompson GE. The use of recombinant activated factor VIIa in coagulopathic traumatic brain injuries requiring emergent craniotomy: is it beneficial? J Neurosurg. 2009;111:666–671. doi: 10.3171/2009.4.JNS081611.
    1. Brown CV, Foulkrod KH, Lopez D, Stokes J, Villareal J, Foarde K, Curry E, Coopwood B. Recombinant factor VIIa for the correction of coagulopathy before emergent craniotomy in blunt trauma patients. J Trauma. 2010;68:348–352. doi: 10.1097/TA.0b013e3181bbfb6b.

Source: PubMed

Sponsors et collaborateurs

Les conditions médicales

Interventions en matière de drogue

3
S'abonner