高亮：Traumatic Brain Injury Associated Coagulopathy

Dept. of Neurosurgery. Huashan Hospital. Fudan University. Shanghai Neurosurgical emergency center Liang Gao ( 高亮 ) Traumatic Brain Injury Associated Coagulopathy

Case File ,[object Object],[object Object],[object Object]

DIAGONOSIS ,[object Object],[object Object],[object Object],[object Object]

DIAGNOSIS- Marshall classification ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],HIGH RISK !!!!!

Initial management ,[object Object],[object Object],[object Object],[object Object]

[object Object],[object Object],[object Object],[object Object]

Traumatic Coagulapathy ,[object Object],[object Object],[object Object]

Transfer to Shanghai 2009.07.10 ,[object Object],[object Object],[object Object],[object Object]

Coagulopathy and TBI ,[object Object],[object Object],[object Object]

Coagulopathy and TBI ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Cell-based Model of Hemostasis Components Endothelial Injury Tissue Factor release Thrombin generation Platelet activation Coagulation factor activation Mathews Neurocritical Care , 2006

Coagulopathy Score SCORE PT(S) aPTT ( S ) Platelet Fibrinogen ( mg/dl ) D-dimer (ng/ml ) 1 <13.5 28~41 ＞ 150 ＞ 180 < 1000 2 >=13.5 <28, >41 ≦ 150 ≦ 180 < 2000 3 >15 ≦ 24, ≧ 46 ≦ 100 ≦ 150 <4000 4 >18 ≧ 61 ≦ 60 ≦ 100 ≧ 4000

Scoring system for diagnosing DIC Prothrombin Index: the percentage of the present prothrombin complex to its normal level

Time course of coagulopathy in isolated s-TBI

Coagulopathy and TBI ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Coagulopathy and TBI ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

TBI and Platelet Dysfunction ,[object Object],[object Object],[object Object],[object Object]

TBI and Hypoperfusion ,[object Object],[object Object],[object Object],[object Object]

TBI and Hypoperfusion ,[object Object],Cohen, Pittett et al, J of Trauma, 2007

TBI and Hypoperfusion ,[object Object],[object Object],[object Object]

Warfarin and TBI ,[object Object],[object Object],[object Object]

Warfarin and TBI ,[object Object]

Warfarin and TBI ,[object Object],Both deaths in the treatment group had >10 hour delay in initiation due to transfer issues

Warfarin-related hemorrhage ,[object Object],[object Object],[object Object],Flibotte et al. Neurology , 2004

Warfarin and TBI ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Warfarin and TBI Ivascu Journal of Trauma 2005

FFP REVERSAL PROTOCAL INR corrected within 24 hours (< 1.4) – Shorter median time to FFP initiation (90 v. 210 min) – 12 of 69 (17%) not reversed by 24 hours This experience neither unique nor acceptable Logistics of FFP or reversal agent itself?

Coagulopathy Reversal ,[object Object],[object Object],[object Object],[object Object],[object Object]

Warfarin Reversal Agents ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Vitamin K ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Fresh Frozen Plasma ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Prothrombin Complex Concentrate ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

rFVIIa ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

rFVIIa in TBI ,[object Object],[object Object],[object Object],[object Object],[object Object],Stein, Scalea et al, J Trauma, 2008

rFVIIa in TBI ,[object Object],[object Object],[object Object],Stein, Scalea et al, J Trauma, 2008

Guidelines for Warfarin Reversal ,[object Object],[object Object]

Reversing heparin ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Antiplatelet Agents ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Saloheimo Stroke 2006; Neurology 2009

Antiplatelet agents – What to Do? ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

TBI-induced Coagulopathy ,[object Object],[object Object],[object Object]

INR & TBI craniotomy ,[object Object],Brown et al. Recombinant Factor VIIa for the Correction of Coagulopathy Before Emergent Craniotomy in Blunt Trauma Patients. Journal of Trauma-Injury Infection & Critical Care,2010

INR & TBI craniotomy ,[object Object],[object Object],Bartal C. J Trauma. 2007 Oct;63(4):725-32.

rFVIIa INR & emergency Craniotomy ,[object Object],Park P. Neurosurgery. 2003 Jul;53(1):34-8;

INR & TBI craniotomy ,[object Object],Stein. J Trauma. 2008 Mar;64(3):620-7;

Coagulopathy & PLT ,[object Object]

高亮：Traumatic Brain Injury Associated Coagulopathy

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