gms | German Medical Science

Objective: Trauma induced coagulopathy (TIC) is a challenge in the management of concomitant polytrauma and traumatic brain injury (TBI). We prospectively analyzed the impact of TIC in polytrauma patients with a TBI on the outcome. The primary endpoint was the neurological outcome as measured by the modified Rankin scale (mRS≥4 unfavorable outcome) at follow-up.

Methods: Adult polytrauma (ISS≥16) patients with a TBI (AIS head≥3) were included. Demographics, injury severity score (ISS), injury mechanism, GCS, pupillary status, coagulation tests, substitution of blood products/antifibrinolytics, emergency surgery, length of ICU/hospital stay, outcome at follow-up were assessed.

cCT findings, progression of hemorrhage (PHC) were analyzed. Coagulation monitoring included thrombocytes, prothrombin time (Quick%), aPTT, fibrinogen, activity of FXIII (%). TIC was defined as the occurrence of at least one of the following: thrombocytes 1.2, aPTT >36 sec., fibrinogen < 2.0 g/L, FXIII <60%. Uni-and multivariate analysis were performed for the following variables: age, sex, ISS, injury mechanism, GCS, pupillary status, type of intracranial hemorrhage, PHC, emergency surgery (<3h), coagulation parameters initial and in the control test, substitution of coagulation factors, transfusion of packed red blood cells.

Results: 84 patients were included in the study. The median ISS was 34 (range 19 – 75). 38.5% had progressive and 5.1% new brain contusions in the control CT scan. The incidence of an aSDH in the initial CT scan was 61.9% (n=52). In 28.2% (n=22), the aSDH was also progredient.

72.6% patients had a TIC at admission. 89.3% patients had an mRS≥4 at discharge. 40.5% patients had an mRS≥4 at follow-up. Higher GCS values (OR 0.65, CI95% 0.46 – 0.93, p=0.018) and higher FXIII activity levels (OR 0.87, CI95% 0.79 – 0.95, p=0.003) were significantly associated with a favorable outcome.

Brain contusions (p=0.069) and their progression (p=0.074) seemed to increase the risk of unfavorable outcome. There was a borderline association between brain contusions and TIC at admission (p=0.058), but the progression of these brain contusions was associated significantly with TIC (p=0.021).

Conclusion: Fibrinogen and FXIII levels emerged as possible predictors of sustained TIC and progression of brain contusions. Nevertheless, further studies need to be undertaken to elucidate further the time course, pathomechanisms and the patient at risk of delayed TIC. Appropriate, meaningful and regular monitoring of the coagulation should guide the therapy.