The Influence of Hemocoagulative Disorders on the Outcome of Children with Head Injury

Abstract

Background: Although disseminated intravascular coagulation (DIC) and other hemocoagulative abnormalities are severe complications of head injury, their effect on clinical outcome remains unclear, particularly among children. Objectives: To evaluate the frequency of hemocoagulative abnormalities and their influence on outcome among children with head injury. Study Design: We conducted a prospective observational study among 60 children with head injury, immediately evaluating severity of head injury (Glasgow Coma Scale, GCS); cerebral axial tomography; prothrombin time; activated partial thromboplastin time (aPTT); fibrinogen level; concentration of fibrin-fibrinogen degradation products (FDP), and platelet count. Two months after injury, we applied the Glasgow Outcome Score (GOS). Associations with GOS were evaluated using univariate and multivariate logistic models. Results: Among children with severe head injury, 22.2% (6/27) developed DIC, all of whom died and had shown severe brain edema. Among those with severe head injury yet without DIC, the mortality was only 14.2%. A low GOS was significantly and independently associated with a low GCS, multiple trauma, delayed aPTT, low fibrinogen level, elevated FDP and low platelet count. Brain edema was also associated with a low GOS, though not significantly. Conclusions: In addition to GCS, type of trauma, type of brain lesion and certain coagulation abnormalities are predictors of GOS.

Distúrbio de coagulação em crianças e adolescentes com traumatismo cranioencefálico moderado e grave

“…7,20 When conjointly analyzed, motor vehicle-pedestrian collisions account for over 70% of cases of moderate to severe TBI in children and adolescents. Such association has also been demonstrated by other authors, 7,8,16,20 who regard falls as another cause of this type of injury.…”

“…Since 1974, when Goodnight et al 9 first ascribed secondary systemic hemostatic failure to acute defibrillation associated with traumatic brain injury that destroyed the brain tissue, several other authors have described the occurrence of coagulopathy in adults and children with TBI, [10][11][12][13][14][15][16][17][18][19] as well as the association between the intensity of the coagulation disorder and the severity of TBI, which reflects the magnitude of the brain injury. 12,[16][17][18] Albeit widely described, the incidence of post-TBI coagulopathy has not been accurately determined among children.…”

“…12,[16][17][18] Albeit widely described, the incidence of post-TBI coagulopathy has not been accurately determined among children. 16 In 1982, Miner et al 12 reported that 71% of patients aged 2 to 18 years admitted to the intensive care unit (ICU) due to TBI had abnormal results in at least one coagulation test. Fifteen years later, May et al, 14 in a study with adults, found out that 81% of patients with an ECG score ≤ 6 on the Glasgow coma scale and that 100% of those with an ECG score < 5 showed laboratory evidence of coagulopathy on admission.…”

“…8,12,13,[15][16][17][18]20 Since the type and extension of the brain injury determine the prognosis and as such injury is subject to deterioration due to impaired hemostasis, the importance and efficacy of treatment of coagulopathy have been widely discussed. [21][22][23] Goodnight et al 9 suggest that the early treatment of coagulopathy may have contributed to a better prognosis of adult patients, which was described by other authors some years later.…”

Fresh Frozen Plasma: Clinical Guidelines and Use

“…8 The development of a laboratory coagulopathy is significantly associated with a higher mortality rate in adults 8,9 and children. 10 In non-survivors, severe brain edema, rather than intracranial hemorrhagic complications, is the most frequent image seen on cerebral axial tomography. Early prophylactic administration of plasma cannot prevent the development of a coagulopathy in these patients.…”